Provider Demographics
NPI:1073012423
Name:MALSON, ANDREA MARION (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:MARION
Last Name:MALSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 SPRINGBORO W STE 201
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1674
Mailing Address - Country:US
Mailing Address - Phone:937-297-8999
Mailing Address - Fax:
Practice Address - Street 1:2633 COMMONS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3827
Practice Address - Country:US
Practice Address - Phone:937-705-6747
Practice Address - Fax:937-705-6713
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OHAPRNCNP024956363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program