Provider Demographics
NPI:1619052081
Name:MALONEY, ELAINE JOY-PETERSON (NP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:JOY-PETERSON
Last Name:MALONEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MUNSON AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:231-935-8540
Mailing Address - Fax:231-935-8544
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-8540
Practice Address - Fax:231-935-8544
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704159600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIEL159600OtherBLUE CROSS
MI104307472Medicaid
MIS58632Medicare UPIN
MI104307472Medicaid