Provider Demographics
NPI:1063011674
Name:MALOTT-STURM, TRICIA RENAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:RENAE
Last Name:MALOTT-STURM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 OTTAWA CT
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61554-1401
Mailing Address - Country:US
Mailing Address - Phone:309-360-1216
Mailing Address - Fax:
Practice Address - Street 1:104 OTTAWA CT
Practice Address - Street 2:
Practice Address - City:MARQUETTE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61554-1401
Practice Address - Country:US
Practice Address - Phone:309-360-1216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.022095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily