Basic Information
| Provider Information | |||||||||
| NPI: | 1487613709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOLLENHOFF | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | RENAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | RENAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD | ||||||||
| Address2: | SUITE 300-N | ||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812862999 | ||||||||
| FaxNumber: | 5126074893 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 9TH ST SW | ||||||||
| Address2: | |||||||||
| City: | WAVERLY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506772929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193524120 | ||||||||
| FaxNumber: | 3192355360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 424 | IA | N | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | IA | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237600000X | 741 | IA | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | IB1798005 | 01 | IA | MEDICARE | OTHER | IB1704005 | 01 | IA | MEDICARE | OTHER | IB1799005 | 01 | IA | MEDICARE | OTHER | IB1796005 | 01 | IA | MEDICARE | OTHER | IB1797005 | 01 | IA | MEDICARE | OTHER | 1148023 | 05 | IA | MEDICAID | IB1795005 | 01 | IA | MEDICARE | OTHER |