Provider Demographics
NPI:1275532624
Name:MALMSTROM, JENNIFER (ARNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MALMSTROM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-341-3015
Mailing Address - Fax:859-341-3215
Practice Address - Street 1:380 CENTRE VIEW BLVD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3476
Practice Address - Country:US
Practice Address - Phone:859-341-3015
Practice Address - Fax:593-413-2158
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400035861Medicare PIN
KYQ38779Medicare UPIN
KY771109Medicare PIN