Provider Demographics
NPI:1376643734
Name:MALLOY, MAUREEN ANNE (CNS,RN)
Entity type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:ANNE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:CNS,RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3536 47TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2939
Mailing Address - Country:US
Mailing Address - Phone:612-721-3066
Mailing Address - Fax:
Practice Address - Street 1:2001 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-301-3433
Practice Address - Fax:612-627-4205
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR056685-8364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN063475100Medicare ID - Type Unspecified