Healthcare Provider Details

I. General information

NPI: 1114263274
Provider Name (Legal Business Name): PATRICIA M MALLOY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 GREATWOOD DRIVE
FLORENCE KY
41042
US

IV. Provider business mailing address

1728 GREATWOOD DRIVE
FLORENCE KY
41042
US

V. Phone/Fax

Practice location:
  • Phone: 951-522-4672
  • Fax:
Mailing address:
  • Phone: 951-522-4672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.399290
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1139622
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN.399290
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN.144965-MEDS
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number224528
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: