MEDICARE: LAURA R WITHORNE-MALONEY CNP

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	363LF0000X	Family Nurse Practitioner	CP000224	SD
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	CP000224	SD
3	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	0224	SD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
15	P00146949	OTHER	SD	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0007942	OTHER	SD	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	48D58WI	OTHER	MN	CC SYSTEMS/ BLUE PLUS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	769191017347	OTHER	SD	PREFERRED ONE
6	797890	OTHER	SD	ARAZ/ AMERICA'S PPO
7	92411422904	OTHER	MN	PRIMEWEST
8	9237794	OTHER	SD	DAKOTACARE
9	HP31902	OTHER	SD	HEALTHPARTNERS
10	25457	OTHER	SD	SANFORD HEALTH PLAN
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	151768	OTHER	MN	UCARE
13	22358	OTHER	SD	MIDLANDS CHOICE
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
16	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
17	57108D008	OTHER	SD	WPS TRICARE

General Provider Information

NPI Number	:	1255303707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA R WITHORNE-MALONEY CNP

Provider Business Mailing Address
First Line	:	2400 S MINNESOTA AVE
Second Line	:	STE 100
City	:	SIOUX FALLS
State	:	SD
Zip	:	57105-3761
Country	:	US
Telephone Number	:	605-322-7510
Fax Number	:	605-322-6475

Provider Business Practice Location Address
First Line	:	4400 W 69TH ST
Second Line	:	STE 500
City	:	SIOUX FALLS
State	:	SD
Zip	:	57108-8170
Country	:	US
Telephone Number	:	605-322-7580
Fax Number	:	605-322-7579

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

Provider Enumeration Date	:	02/07/2006
Last Update Date	:	12/11/2013

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