Provider Demographics
NPI:1467449710
Name:MALLOY, MICHELLE M (ARNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MALLOY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE PLAINE
Mailing Address - State:IA
Mailing Address - Zip Code:52208-2200
Mailing Address - Country:US
Mailing Address - Phone:319-444-3210
Mailing Address - Fax:319-444-4099
Practice Address - Street 1:105 9TH AVE
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:IA
Practice Address - Zip Code:52208-2200
Practice Address - Country:US
Practice Address - Phone:319-444-3210
Practice Address - Fax:319-444-4099
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC087828207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1467449710Medicaid
IA72238OtherWELLMARK UIQC SEIC
IA500030815OtherRR MEDICARE
IA72237OtherWELLMARK UIQC OCTC
IA72239OtherWELLMARK UIQC NL
IA500030815OtherRR MEDICARE
S64627Medicare UPIN
IA1467449710Medicaid