Provider Demographics
NPI:1265642573
Name:MALOY, DEREA MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DEREA
Middle Name:MARIE
Last Name:MALOY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 COUNTY ROAD 1675
Mailing Address - Street 2:
Mailing Address - City:JEROMESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44840-9636
Mailing Address - Country:US
Mailing Address - Phone:419-368-8494
Mailing Address - Fax:419-368-8233
Practice Address - Street 1:226 COUNTY ROAD 1675
Practice Address - Street 2:
Practice Address - City:JEROMESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44840-9636
Practice Address - Country:US
Practice Address - Phone:419-368-8494
Practice Address - Fax:419-368-8233
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN106348164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse