Provider Demographics
NPI:1093168213
Name:MALESEV, TAMARA (NP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MALESEV
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:
Other - Last Name:MALESEV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:12700 LAKE AVE APT 1102
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1530
Mailing Address - Country:US
Mailing Address - Phone:216-544-5387
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:216-544-5387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.19068-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1093168213OtherADULT/GERONTOLOGY