Healthcare Provider Details

I. General information

NPI: 1013139021
Provider Name (Legal Business Name): THERESA KIMBERLEY MALMON-BERG M.S.N., C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 CLEVELAND RD
WOOSTER OH
44691-2204
US

IV. Provider business mailing address

907 FOREST DR.
WOOSTER OH
44691
US

V. Phone/Fax

Practice location:
  • Phone: 330-287-4500
  • Fax:
Mailing address:
  • Phone: 330-262-4501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP05937
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: