Healthcare Provider Details

I. General information

NPI: 1649564964
Provider Name (Legal Business Name): NICOLE M. MALLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 TUNICA DR E
MARKSVILLE LA
71351-3076
US

IV. Provider business mailing address

1012 PETROLEUM PKWY
BROUSSARD LA
70518-8020
US

V. Phone/Fax

Practice location:
  • Phone: 318-717-1175
  • Fax: 210-924-4113
Mailing address:
  • Phone: 337-465-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7387
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number311571
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: