Provider Demographics
NPI:1992831994
Name:MASIONGALE, MALISSA
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:MASIONGALE
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 1:716 OAKLEY ALLONS RD
Mailing Address - Street 2:
Mailing Address - City:ALLONS
Mailing Address - State:TN
Mailing Address - Zip Code:38541-6924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5880 BRADFORD HICKS DR
Practice Address - Street 2:TN DEPT OF HEALTH
Practice Address - City:LIVINGSTON
Practice Address - State:TN
Practice Address - Zip Code:38570-2236
Practice Address - Country:US
Practice Address - Phone:931-823-6260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34458164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse