Provider Demographics
NPI:1578600441
Name:MALICK, MARY LORRAINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LORRAINE
Last Name:MALICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LORRAINE
Other - Last Name:MALICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, CNS, FNP-C
Mailing Address - Street 1:601 WALL ST.
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:219-384-6178
Mailing Address - Fax:
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-531-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000085A363LF0000X
IL209.010129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily