Provider Demographics
NPI:1871162016
Name:MYNURSEPRACTITIONER
Entity type:Organization
Organization Name:MYNURSEPRACTITIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:206-659-7193
Mailing Address - Street 1:539 W COMMERCE ST # 881
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-1953
Mailing Address - Country:US
Mailing Address - Phone:206-659-7193
Mailing Address - Fax:949-655-7898
Practice Address - Street 1:539 W COMMERCE ST # 881
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-1953
Practice Address - Country:US
Practice Address - Phone:206-659-7193
Practice Address - Fax:949-655-7898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty