Provider Demographics
NPI:1881454064
Name:ANDERSON, MOLLY MAE (PMHNP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MAE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37918 STATE HIGHWAY 87
Mailing Address - Street 2:
Mailing Address - City:FRAZEE
Mailing Address - State:MN
Mailing Address - Zip Code:56544-9406
Mailing Address - Country:US
Mailing Address - Phone:701-936-4357
Mailing Address - Fax:
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11407363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health