Provider Demographics
NPI:1043030877
Name:PROVOLT, MOLLIE
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:PROVOLT
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 1:13538 EVELYN ST
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080
Mailing Address - Country:US
Mailing Address - Phone:808-666-1592
Mailing Address - Fax:
Practice Address - Street 1:1901 BARNEY RD.
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007
Practice Address - Country:US
Practice Address - Phone:530-665-8402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker