Provider Demographics
NPI:1891276481
Name:MALONE, BRANDI MICHELE (ACAGNP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELE
Last Name:MALONE
Suffix:
Gender:F
Credentials:ACAGNP
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 1120
Mailing Address - Street 2:
Mailing Address - City:FRANKSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75763-1120
Mailing Address - Country:US
Mailing Address - Phone:903-570-0596
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138255208M00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1G8783OtherMEDICARE
TX407522803Medicaid
TX1G0062OtherMEDICARE
TX407522802Medicaid