Healthcare Provider Details

I. General information

NPI: 1124307210
Provider Name (Legal Business Name): DANIELLE MALONE R-PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 11/27/2023
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 845-333-7575
  • Fax: 845-333-1454
Mailing address:
  • Phone: 845-333-7575
  • Fax: 845-333-1454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014959
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number014959
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: