MEDICARE: KRISTI LYNN MALICOAT LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	200930022LPN	OR
2	164W00000X	Licensed Practical Nurse	PN-12009	ID
3	164W00000X	Licensed Practical Nurse	27036628A	IN
4	164W00000X	Licensed Practical Nurse	LPN11423	NV
5	164X00000X	Licensed Vocational Nurse	VN249377	CA

General Provider Information

NPI Number	:	1013232834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTI LYNN MALICOAT LPN

Provider Business Mailing Address
First Line	:	PO BOX 632
Second Line	:
City	:	GRAND VIEW
State	:	ID
Zip	:	83624-0632
Country	:	US
Telephone Number	:	208-834-2860
Fax Number	:

Provider Business Practice Location Address
First Line	:	23220 RIVER RD
Second Line	:
City	:	GRAND VIEW
State	:	ID
Zip	:	83624-5009
Country	:	US
Telephone Number	:	208-834-2860
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2010
Last Update Date	:	05/09/2011

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