Provider Demographics
NPI:1619057031
Name:COOLING, MALINDA
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:
Last Name:COOLING
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 1:401 N MAIN
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IL
Mailing Address - Zip Code:61561
Mailing Address - Country:US
Mailing Address - Phone:309-923-2661
Mailing Address - Fax:309-923-7628
Practice Address - Street 1:401 N MAIN
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561
Practice Address - Country:US
Practice Address - Phone:309-923-2661
Practice Address - Fax:309-923-7628
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041309753/209004800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00086872 / CA4079Medicare ID - Type UnspecifiedRR
Q02062Medicare UPIN
IL207594Medicare ID - Type UnspecifiedGROUP #
ILK02208Medicare ID - Type UnspecifiedINDIVIDUAL #