Provider Demographics
NPI:1366937716
Name:MYSLENSKI, MALLORY ANN (AGNP-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:MYSLENSKI
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ANN
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2122 HEALTH DR SW STE 133
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5950
Practice Address - Fax:616-252-5956
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG06180160363L00000X, 363LP2300X, 363LA2200X, 363LG0600X
MI4704301141363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1366937716Medicaid