Provider Demographics
NPI:1053785063
Name:MOLLOY, EDWARD MCCORMACK (RN)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:MCCORMACK
Last Name:MOLLOY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 OLD COUNTRY RD UNIT 428
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-4420
Mailing Address - Country:US
Mailing Address - Phone:631-375-9727
Mailing Address - Fax:
Practice Address - Street 1:1661 OLD COUNTRY RD UNIT 428
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4420
Practice Address - Country:US
Practice Address - Phone:631-375-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY709109372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion