Healthcare Provider Details

I. General information

NPI: 1376643734
Provider Name (Legal Business Name): MAUREEN ANNE MALLOY C.N.S.,R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

IV. Provider business mailing address

3536 47TH AVE S
MINNEAPOLIS MN
55406-2939
US

V. Phone/Fax

Practice location:
  • Phone: 612-301-3433
  • Fax: 612-627-4205
Mailing address:
  • Phone: 612-721-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR056685-8
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: