Provider Demographics
NPI:1326593310
Name:MALLEY, NIKKI MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:NIKKI
Middle Name:MARIE
Last Name:MALLEY
Suffix:
Gender:F
Credentials:FNP
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Mailing Address - Street 1:1500 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3318
Mailing Address - Country:US
Mailing Address - Phone:573-686-4151
Mailing Address - Fax:573-778-4260
Practice Address - Street 1:1500 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3318
Practice Address - Country:US
Practice Address - Phone:573-686-4151
Practice Address - Fax:573-778-4260
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL277000304363LF0000X
MO2015043931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily