Provider Demographics
NPI:1043878259
Name:MOLLA, ETENESH (NP)
Entity type:Individual
Prefix:
First Name:ETENESH
Middle Name:
Last Name:MOLLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18980 W MEMORIAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-4394
Mailing Address - Country:US
Mailing Address - Phone:972-693-3455
Mailing Address - Fax:
Practice Address - Street 1:2727 BOLTON BOONE DR STE 109
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2019
Practice Address - Country:US
Practice Address - Phone:469-988-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138863363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily