Provider Demographics
NPI:1912961228
Name:STAPLETON, MOLLIE A (MD)
Entity Type:Individual
Prefix:MRS
First Name:MOLLIE
Middle Name:A
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55806-2719
Mailing Address - Country:US
Mailing Address - Phone:218-525-0557
Mailing Address - Fax:
Practice Address - Street 1:927 TRETTEL LANE
Practice Address - Street 2:FOND DU LAC HUMAN SERVICES DIVISION
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720
Practice Address - Country:US
Practice Address - Phone:218-879-1227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN383818800Medicaid
MN08001258Medicare ID - Type Unspecified
MN383818800Medicaid