Provider Demographics
NPI:1699944124
Name:MALICOAT, DEANNA KAY (CNS)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:KAY
Last Name:MALICOAT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 BALCONES DR
Mailing Address - Street 2:STE. 102
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4270
Mailing Address - Country:US
Mailing Address - Phone:512-323-5362
Mailing Address - Fax:
Practice Address - Street 1:6010 BALCONES DR
Practice Address - Street 2:STE. 102
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-4270
Practice Address - Country:US
Practice Address - Phone:512-323-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX640904364SA2200X
TXAP116729364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197820703Medicaid
TX197820703Medicaid