Healthcare Provider Details

I. General information

NPI: 1275809741
Provider Name (Legal Business Name): NICOLE CHRISTINE MALLORY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

IV. Provider business mailing address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

V. Phone/Fax

Practice location:
  • Phone: 732-923-7455
  • Fax: 732-923-7451
Mailing address:
  • Phone: 732-923-7455
  • Fax: 732-923-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA10637200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number25MA10637200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: