Provider Demographics
NPI:1013232834
Name:MALICOAT, KRISTI LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:LYNN
Last Name:MALICOAT
Suffix:
Gender:F
Credentials:LPN
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 632
Mailing Address - Street 2:
Mailing Address - City:GRAND VIEW
Mailing Address - State:ID
Mailing Address - Zip Code:83624-0632
Mailing Address - Country:US
Mailing Address - Phone:208-834-2860
Mailing Address - Fax:
Practice Address - Street 1:23220 RIVER RD
Practice Address - Street 2:
Practice Address - City:GRAND VIEW
Practice Address - State:ID
Practice Address - Zip Code:83624-5009
Practice Address - Country:US
Practice Address - Phone:208-834-2860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200930022LPN164W00000X
IDPN-12009164W00000X
IN27036628A164W00000X
NVLPN11423164W00000X
CAVN249377164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse