Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 10383R | LA |
NPI | 1942366729 |
---|---|
Provider Name | R. Mollie A. John |
First Address | Monroe, LA 71201-3048 |
Second Address | Monroe, LA 71201-3048 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1989258 | (05) | LA |
F86057 | (02) | LA |