Provider Demographics
NPI:1750776100
Name:TWELLMAN, MOLLY M (ANP)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:M
Last Name:TWELLMAN
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MISS
Other - First Name:MOLLY
Other - Middle Name:M
Other - Last Name:WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:10012 KENNERLY RD
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:314-880-6676
Mailing Address - Fax:314-842-4372
Practice Address - Street 1:10012 KENNERLY RD
Practice Address - Street 2:SUITE 403
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:314-880-6676
Practice Address - Fax:314-842-4372
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015009936363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3163029Medicare PIN