Provider Demographics
NPI:1013139021
Name:MALMON-BERG, THERESA KIMBERLEY (MSN, CNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:KIMBERLEY
Last Name:MALMON-BERG
Suffix:
Gender:F
Credentials:MSN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 FOREST DR.
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691
Mailing Address - Country:US
Mailing Address - Phone:330-262-4501
Mailing Address - Fax:
Practice Address - Street 1:1740 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2204
Practice Address - Country:US
Practice Address - Phone:330-287-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP05937363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily