Provider Demographics
NPI:1073153219
Name:MALENKOS, MARISSA SUZANNE
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:SUZANNE
Last Name:MALENKOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8929 SOURWOOD CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1544
Mailing Address - Country:US
Mailing Address - Phone:317-760-6926
Mailing Address - Fax:
Practice Address - Street 1:2020 W 86TH ST STE 306
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1931
Practice Address - Country:US
Practice Address - Phone:317-602-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28174774A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily