Healthcare Provider Details

I. General information

NPI: 1215343298
Provider Name (Legal Business Name): MALLORY KISLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MERRICK AVE STE 109
EAST MEADOW NY
11554-1580
US

IV. Provider business mailing address

30 MERRICK AVE STE 109
EAST MEADOW NY
11554-1580
US

V. Phone/Fax

Practice location:
  • Phone: 516-416-4588
  • Fax:
Mailing address:
  • Phone: 516-416-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number57002525
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: