Provider Demographics
NPI:1386227239
Name:ERICKSON, MALENA LANDON (OD)
Entity Type:Individual
Prefix:DR
First Name:MALENA
Middle Name:LANDON
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 CUNNIFF RD
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015-2701
Mailing Address - Country:US
Mailing Address - Phone:615-719-3534
Mailing Address - Fax:
Practice Address - Street 1:712 FORTINO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2084
Practice Address - Country:US
Practice Address - Phone:719-542-0236
Practice Address - Fax:719-542-8699
Is Sole Proprietor?:No
Enumeration Date:2021-04-29
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COOPT.0003678152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program