Healthcare Provider Details

I. General information

NPI: 1194305722
Provider Name (Legal Business Name): HEATHER MALIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 COLLEGE DR STE 2A
VINELAND NJ
08360-6933
US

IV. Provider business mailing address

148 ALDER AVE
EGG HARBOR TWP NJ
08234-5331
US

V. Phone/Fax

Practice location:
  • Phone: 856-641-8680
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00609800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: