Provider Demographics
NPI:1285894246
Name:MALOTT, REBECCA E (ACNP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:E
Last Name:MALOTT
Suffix:
Gender:
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B2ND
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:
Practice Address - Street 1:5275 STATE ROUTE 122 STE 200
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-9617
Practice Address - Country:US
Practice Address - Phone:513-217-6400
Practice Address - Fax:513-217-6037
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-300662363LA2100X
OHNP-10005363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2867509Medicaid
OH000000579135OtherANTHEM
OHP00706035OtherRAILROAD
OHP00706035OtherRAILROAD
OH000000579135OtherANTHEM