Basic Information
| Provider Information | |||||||||
| NPI: | 1255594610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALOTT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404466 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3130 N COUNTY ROAD 25A | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453731337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374404466 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | NP-5805 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 98073 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | COA13729NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0074816 | 05 | OH | MEDICAID |