Provider Demographics
NPI:1710592175
Name:MALONEY, MARY E (ANP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MALONEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5342
Mailing Address - Country:US
Mailing Address - Phone:618-767-7023
Mailing Address - Fax:
Practice Address - Street 1:4315 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5342
Practice Address - Country:US
Practice Address - Phone:618-767-7023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023096363LA2200X, 363L00000X
ILAG06200301363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology