Basic Information
| Provider Information | |||||||||
| NPI: | 1396786034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLOW | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1509 DULLES DR | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705063718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 MON HEALTH DRIVE | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265052853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3379919276 | ||||||||
| FaxNumber: | 3379430846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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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 | 363L00000X | 0024174910 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | NP 01828 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | APRN99622 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 341847368040 | 01 | OH | CARESOURCE | OTHER | MM0567923 | 01 | OH | DEA | OTHER | 000000553547 | 01 | OH | ANTHEM | OTHER | 2321722 | 05 | OH | MEDICAID | 1396786034 | 05 | WV | MEDICAID |