Provider Demographics
NPI:1568943595
Name:MINTON, MALISSA MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:MALISSA
Middle Name:MARIE
Last Name:MINTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-6442
Mailing Address - Country:US
Mailing Address - Phone:937-694-4296
Mailing Address - Fax:
Practice Address - Street 1:422 SYCAMORE DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-6442
Practice Address - Country:US
Practice Address - Phone:937-694-4296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.451053163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse