Healthcare Provider Details

I. General information

NPI: 1487658316
Provider Name (Legal Business Name): SUSAN MARIE MALLONE-STEAD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUSAN M STEAD APRN

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4751 S CLEVELAND AVE
FORT MYERS FL
33907-1317
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9888
  • Fax: 239-343-9868
Mailing address:
  • Phone: 239-343-9888
  • Fax: 239-343-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9395706
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAPRN9395706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: