Provider Demographics
NPI:1083341572
Name:MALOTT, KERRIANN MARIA (BSN,RN)
Entity Type:Individual
Prefix:
First Name:KERRIANN
Middle Name:MARIA
Last Name:MALOTT
Suffix:
Gender:F
Credentials:BSN,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N BERGIN LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NM
Mailing Address - Zip Code:87413-6729
Mailing Address - Country:US
Mailing Address - Phone:505-632-4337
Mailing Address - Fax:505-632-4371
Practice Address - Street 1:325 N BERGIN LN
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-6729
Practice Address - Country:US
Practice Address - Phone:505-632-4337
Practice Address - Fax:505-632-4371
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM59774163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice