Healthcare Provider Details

I. General information

NPI: 1932172681
Provider Name (Legal Business Name): PRISCILLA B MALLOY AP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9300
  • Fax: 860-545-9301
Mailing address:
  • Phone: 860-545-9300
  • Fax: 860-545-9301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0200X
TaxonomyPediatric Clinical Nurse Specialist
License Number000209
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberR32068
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: