Provider Demographics
NPI:1982205860
Name:MALOTT, GINA RENAE (APRN)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:RENAE
Last Name:MALOTT
Suffix:
Gender:F
Credentials:APRN
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 643398
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-3398
Mailing Address - Country:US
Mailing Address - Phone:513-221-1100
Mailing Address - Fax:513-684-4501
Practice Address - Street 1:3825 EDWARDS RD STE 300
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45209-1288
Practice Address - Country:US
Practice Address - Phone:513-221-1100
Practice Address - Fax:513-684-4501
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027915363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2565399Medicaid