Healthcare Provider Details

I. General information

NPI: 1174780175
Provider Name (Legal Business Name): SUZANNE FLINT MALLOY NP MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MAIN ST
AGAWAM MA
01001-1838
US

IV. Provider business mailing address

230 MAIN ST
AGAWAM MA
01001-1838
US

V. Phone/Fax

Practice location:
  • Phone: 413-789-6800
  • Fax:
Mailing address:
  • Phone: 413-789-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number165493
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: