Basic Information
| Provider Information | |||||||||
| NPI: | 1720244395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COUSIN | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | KRISTINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2906 S 20TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146721353 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2008 | ||||||||
| LastUpdateDate: | 10/10/2013 | ||||||||
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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 | 208000000X | MT193350 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 54078 | MN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 60657-20 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.