Provider Demographics
NPI:1306341250
Name:MALONE, DEBREKA SHENETTE
Entity type:Individual
Prefix:MRS
First Name:DEBREKA
Middle Name:SHENETTE
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 SUMMER WIND DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-7021
Mailing Address - Country:US
Mailing Address - Phone:281-414-8776
Mailing Address - Fax:
Practice Address - Street 1:4416 FAIRMONT PKWY STE 108
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77504-3327
Practice Address - Country:US
Practice Address - Phone:281-487-0402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2018002325363LF0000X
GA2018002325363LF0000X
TX2018002325363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2018002325Medicaid