Provider Demographics
NPI:1639279425
Name:MALONE, KAWANNA CORRINE (CFNP)
Entity Type:Individual
Prefix:
First Name:KAWANNA
Middle Name:CORRINE
Last Name:MALONE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:KAWANNA
Other - Middle Name:CORRINE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:361 CR 122
Mailing Address - Street 2:
Mailing Address - City:NETTLETON
Mailing Address - State:MS
Mailing Address - Zip Code:38858-6026
Mailing Address - Country:US
Mailing Address - Phone:662-825-1086
Mailing Address - Fax:
Practice Address - Street 1:1495 MAPLE RD
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858-6026
Practice Address - Country:US
Practice Address - Phone:662-963-9146
Practice Address - Fax:662-963-9186
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR682403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05774270Medicaid
MS512I500093Medicare UPIN