1255303707 NPI number — LAURA R WITHORNE-MALONEY CNP

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255303707 NPI number — LAURA R WITHORNE-MALONEY CNP

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WITHORNE-MALONEY

Provider First Name:

LAURA

Provider Middle Name:

R

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

CNP

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1255303707

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/11/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2400 S MINNESOTA AVE

Provider Second Line Business Mailing Address:

STE 100

Provider Business Mailing Address City Name:

SIOUX FALLS

Provider Business Mailing Address State Name:

SD

Provider Business Mailing Address Postal Code:

57105-3761

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

605-322-7510

Provider Business Mailing Address Fax Number:

605-322-6475

Provider First Line Business Practice Location Address:

4400 W 69TH ST

Provider Second Line Business Practice Location Address:

STE 500

Provider Business Practice Location Address City Name:

SIOUX FALLS

Provider Business Practice Location Address State Name:

SD

Provider Business Practice Location Address Postal Code:

57108-8170

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

605-322-7580

Provider Business Practice Location Address Fax Number:

605-322-7579

Provider Enumeration Date:

02/07/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LF0000X , with the licence number:  CP000224 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 363LP0808X , with the licence number: CP000224 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 364SP0808X , with the licence number: 0224 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 0007942 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 1908517 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
• Identifier: 48D58WI . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 6826062 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
• Identifier: 769191017347 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 797890 . This is a "ARAZ/ AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 92411422904 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 9237794 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: HP31902 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 25457 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 393603100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
• Identifier: 151768 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
• Identifier: 22358 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 46022474340 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: P00146949 . This is a "RR MEDICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
• Identifier: 12242 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
• Identifier: 57108D008 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".