Basic Information
| Provider Information | |||||||||
| NPI: | 1811276751 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MALONEY | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | MEDPARTNERS, ATTN: BARB COPELAND | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7916 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604322297 | ||||||||
| FaxNumber: | 2604346481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2011 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71003728A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201034410 | 05 | IN | MEDICAID |