Provider Demographics
NPI:1235123779
Name:MOLYET, EILEEN (CRNA)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:MOLYET
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SE ALFRED MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-2204
Mailing Address - Country:US
Mailing Address - Phone:386-697-1364
Mailing Address - Fax:888-370-3379
Practice Address - Street 1:421 SE ALFRED MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-2204
Practice Address - Country:US
Practice Address - Phone:386-697-1364
Practice Address - Fax:888-370-3379
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1257132367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG0073OtherBLUE SHIELD PROV #
FL305412800Medicaid
FL305412800Medicaid
FLG0073EMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER