Provider Demographics
NPI:1457398729
Name:DOTY, MOLLIE (CFNP)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:DOTY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 1052
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-981-9503
Mailing Address - Fax:601-982-0148
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 1052
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-981-9503
Practice Address - Fax:601-982-0148
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852249363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ42746Medicare UPIN