MEDICARE: KIMBERLY MALLOY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	713152	NY

General Provider Information

NPI Number	:	1962978882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY MALLOY RN

Provider Business Mailing Address
First Line	:	115 W 172ND ST APT 5G
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10452-1849
Country	:	US
Telephone Number	:	917-757-7821
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 W 172ND ST APT 5G
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10452-1849
Country	:	US
Telephone Number	:	917-757-7821
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2018
Last Update Date	:	10/18/2018

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