Provider Demographics
NPI:1255463030
Name:MALIKOWSKI, SHANNON L (CNP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:L
Last Name:MALIKOWSKI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4103
Mailing Address - Country:US
Mailing Address - Phone:419-756-6000
Mailing Address - Fax:419-756-1774
Practice Address - Street 1:500 S TRIMBLE RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4103
Practice Address - Country:US
Practice Address - Phone:419-756-6000
Practice Address - Fax:419-756-1774
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-06714363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2400137Medicaid
OHP42128Medicare UPIN