Provider Demographics
NPI:1649971334
Name:MOLINE, FRED
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:MOLINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 NE 160TH TER
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4339
Mailing Address - Country:US
Mailing Address - Phone:305-927-6073
Mailing Address - Fax:
Practice Address - Street 1:5510 N HESPERIDES ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5414
Practice Address - Country:US
Practice Address - Phone:813-467-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025185363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty