Healthcare Provider Details

I. General information

NPI: 1104763358
Provider Name (Legal Business Name): MALISSA JEAN DRIVER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

IV. Provider business mailing address

4101 WOOLWORTH AVE
OMAHA NE
68105-1850
US

V. Phone/Fax

Practice location:
  • Phone: 402-995-6913
  • Fax: 402-930-7975
Mailing address:
  • Phone: 402-995-6913
  • Fax: 402-930-7975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number123867
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: