Provider Demographics
NPI:1558837765
Name:MALONE, SHIRLEY A
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:A
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3488 STELLHORN RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-4630
Mailing Address - Country:US
Mailing Address - Phone:260-755-6589
Mailing Address - Fax:
Practice Address - Street 1:3488 STELLHORN RD UNIT B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-4630
Practice Address - Country:US
Practice Address - Phone:260-755-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18-014453-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300017609Medicaid