Provider Demographics
NPI:1851863252
Name:MALICOAT, BRANNAN DANIELLE (MSN, APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:BRANNAN
Middle Name:DANIELLE
Last Name:MALICOAT
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:BRANNAN
Other - Middle Name:D
Other - Last Name:COBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1111 RONALD REAGAN PKWY STE 1100
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7085
Practice Address - Country:US
Practice Address - Phone:317-944-7874
Practice Address - Fax:317-968-1067
Is Sole Proprietor?:No
Enumeration Date:2018-12-23
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008706A363LF0000X
INF10181240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300040824Medicaid
IN233690179OtherMEDICARE PTAN
IN677730052OtherMEDICARE