Provider Demographics
NPI:1811349004
Name:STOMMES, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:STOMMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 STOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2149
Mailing Address - Country:US
Mailing Address - Phone:952-448-6557
Mailing Address - Fax:
Practice Address - Street 1:1045 STOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318
Practice Address - Country:US
Practice Address - Phone:952-448-6557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4631363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner