Provider Demographics
NPI:1417984352
Name:MALLATT, SUZANNE T (NP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:T
Last Name:MALLATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9473 SE 80TH TER
Mailing Address - Street 2:
Mailing Address - City:BAXTER SPRINGS
Mailing Address - State:KS
Mailing Address - Zip Code:66713-3278
Mailing Address - Country:US
Mailing Address - Phone:620-848-9826
Mailing Address - Fax:918-540-1685
Practice Address - Street 1:7600 S HIGHWAY 69A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1016
Practice Address - Country:US
Practice Address - Phone:918-542-1655
Practice Address - Fax:918-540-1685
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO147011363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425773108Medicaid
P52665Medicare UPIN
MO000081198Medicare ID - Type Unspecified