Provider Demographics
NPI:1720184781
Name:MALONE, GWEN BONITA (CRNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:BONITA
Last Name:MALONE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21231
Mailing Address - Street 2:200 UNIVERSITY BLVD
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35402-0707
Mailing Address - Country:US
Mailing Address - Phone:205-759-0633
Mailing Address - Fax:205-759-0635
Practice Address - Street 1:200 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35402-0707
Practice Address - Country:US
Practice Address - Phone:205-759-0633
Practice Address - Fax:205-759-0635
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1044329363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner