Provider Demographics
NPI:1053157123
Name:WALLIS, MOLLY (APRN FNP-C)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 HEATHROW DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-3831
Mailing Address - Country:US
Mailing Address - Phone:386-795-2756
Mailing Address - Fax:
Practice Address - Street 1:1667 N CLYDE MORRIS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5500
Practice Address - Country:US
Practice Address - Phone:386-274-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily