Provider Demographics
NPI:1447244132
Name:MALONE, LARRY D (FNP)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:D
Last Name:MALONE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1240
Mailing Address - Country:US
Mailing Address - Phone:936-569-6411
Mailing Address - Fax:936-569-6446
Practice Address - Street 1:320 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1240
Practice Address - Country:US
Practice Address - Phone:936-569-6411
Practice Address - Fax:936-569-6446
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX601491363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N3041OtherBCBS PROVIDER #
TXP39268Medicare UPIN
TX8N3041OtherBCBS PROVIDER #