Provider Demographics
NPI:1619219003
Name:MALONE, CAROL MARIE (AGNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:MARIE
Last Name:MALONE
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:500 KIRTS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4134
Practice Address - Country:US
Practice Address - Phone:248-824-6060
Practice Address - Fax:248-686-0772
Is Sole Proprietor?:No
Enumeration Date:2013-03-23
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704182052363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health