Healthcare Provider Details

I. General information

NPI: 1851578520
Provider Name (Legal Business Name): MAURA O'MALLEY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE ROAD STATEN ISLAND PHYSICIAN PRACTICE
STATEN ISLAND NY
10304-5509
US

IV. Provider business mailing address

2791 RICHMOND AVE SUITE 201
STATEN ISLAND NY
10314-5882
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax: 718-816-3749
Mailing address:
  • Phone: 718-816-6440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF304408-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: