Provider Demographics
NPI:1396786034
Name:MALLOW, KAREN LOUISE (CNP)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LOUISE
Last Name:MALLOW
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 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:337-991-9276
Mailing Address - Fax:337-943-0846
Practice Address - Street 1:30 MON HEALTH DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-2853
Practice Address - Country:US
Practice Address - Phone:337-991-9276
Practice Address - Fax:337-943-0846
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174910363L00000X
OHNP 01828363LA2200X
WVAPRN99622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341847368040OtherCARESOURCE
OH000000553547OtherANTHEM
OH2321722Medicaid
WV1396786034Medicaid
WV1396786034Medicaid
OHNP13212Medicare PIN
OH000000553547OtherANTHEM
OHP00466287Medicare PIN