Provider Demographics
NPI:1689615494
Name:KINNISON, MALONNIE L (MD)
Entity Type:Individual
Prefix:
First Name:MALONNIE
Middle Name:L
Last Name:KINNISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 E GEDDES AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3800
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:303-761-6278
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:303-761-6278
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00274772085R0202X, 2085R0204X
NE249202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD439851300Medicaid
NEP01105939Medicare PIN
MD439851300Medicaid
B70567Medicare UPIN
MD527L668CMedicare PIN
NENA1214074Medicare PIN
NENA1215074Medicare PIN