MEDICARE: MRS. SUSAN MARIE MALLONE-STEAD APRN

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	APRN9395706	FL
2	363LP0200X	Pediatric Nurse Practitioner	APRN9395706	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487658316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN MARIE MALLONE-STEAD APRN

Provider Business Mailing Address
First Line	:	PO BOX 2147
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33902-2147
Country	:	US
Telephone Number	:	239-343-9888
Fax Number	:	239-343-9868

Provider Business Practice Location Address
First Line	:	4751 S CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-1317
Country	:	US
Telephone Number	:	239-343-9888
Fax Number	:	239-343-9868

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	01/31/2022

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