Provider Demographics
NPI:1245267657
Name:HEINRICH, MOLLY MARIE (PAC)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:MARIE
Last Name:HEINRICH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:MARIE
Other - Last Name:SIMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1656 MEDICAL BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1423
Mailing Address - Country:US
Mailing Address - Phone:392-799-7057
Mailing Address - Fax:239-799-2131
Practice Address - Street 1:1656 MEDICAL BLVD STE 301
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1423
Practice Address - Country:US
Practice Address - Phone:239-799-7057
Practice Address - Fax:239-799-2131
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004759363A00000X, 363AS0400X
FLPA9108022363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11712583OtherCAQH