Provider Demographics
NPI:1831180405
Name:MALLION, KATHERINE E (PA-C, CNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:MALLION
Suffix:
Gender:F
Credentials:PA-C, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W FIR ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-5703
Mailing Address - Country:US
Mailing Address - Phone:575-356-6695
Mailing Address - Fax:575-356-5948
Practice Address - Street 1:1511 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5407
Practice Address - Country:US
Practice Address - Phone:575-623-3255
Practice Address - Fax:575-625-9901
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM94PA26363L00000X, 363L00000X
NMCNP00188363LW0102X
NM94-PA26363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91544Medicaid
R81963Medicare UPIN
PA009426Medicare ID - Type Unspecified