Provider Demographics
NPI:1790386423
Name:CUSTER, MALYNDA MARIE
Entity Type:Individual
Prefix:
First Name:MALYNDA
Middle Name:MARIE
Last Name:CUSTER
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 1:7937 VAN WERT WILLSHIRE RD APT SUITE
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-8959
Mailing Address - Country:US
Mailing Address - Phone:419-203-1035
Mailing Address - Fax:
Practice Address - Street 1:7937 VAN WERT WILLSHIRE RD APT SUITE
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-8959
Practice Address - Country:US
Practice Address - Phone:419-203-1035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver