Provider Demographics
NPI:1871795583
Name:KELLEY, MOLLY (BSN, MSN, CPNP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:BSN, MSN, CPNP
Other - Prefix:MS
Other - First Name:MOLLY
Other - Middle Name:KELLEY
Other - Last Name:EIMERMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, MS, CPNP
Mailing Address - Street 1:2880 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3644
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2880 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3644
Practice Address - Country:US
Practice Address - Phone:608-332-6676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1646-33363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43917900Medicaid