Provider Demographics
NPI:1831350172
Name:MALOOLY, LEANNE M (NP)
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:M
Last Name:MALOOLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 CLEARVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-5026
Mailing Address - Country:US
Mailing Address - Phone:208-233-9340
Mailing Address - Fax:
Practice Address - Street 1:4800 CLEARVIEW AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-5026
Practice Address - Country:US
Practice Address - Phone:208-233-9340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP18981-A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily