Provider Demographics
NPI:1831621945
Name:DURBIN, MOLLY SHAWNAKAYE
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:SHAWNAKAYE
Last Name:DURBIN
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 1:510 LEAVERTON ST
Mailing Address - Street 2:APT. #6
Mailing Address - City:POCAHONTAS
Mailing Address - State:IL
Mailing Address - Zip Code:62275-3010
Mailing Address - Country:US
Mailing Address - Phone:618-570-1102
Mailing Address - Fax:
Practice Address - Street 1:510 LEAVERTON ST
Practice Address - Street 2:APT. #6
Practice Address - City:POCAHONTAS
Practice Address - State:IL
Practice Address - Zip Code:62275-3010
Practice Address - Country:US
Practice Address - Phone:618-570-1102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL113860332Medicaid