Provider Demographics
NPI:1750985388
Name:DEJESUS, MOLLY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:DEJESUS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 OSBORN LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-4525
Mailing Address - Country:US
Mailing Address - Phone:856-506-5693
Mailing Address - Fax:
Practice Address - Street 1:105 MANHEIM AVE STE 7
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2139
Practice Address - Country:US
Practice Address - Phone:856-451-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01083000363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health