Healthcare Provider Details

I. General information

NPI: 1891776555
Provider Name (Legal Business Name): JUDITH ANNE MALONEY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SHERMAN ST
WATERTOWN NY
13601-3612
US

IV. Provider business mailing address

228 SHERMAN ST
WATERTOWN NY
13601-3615
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-9849
  • Fax:
Mailing address:
  • Phone: 315-788-9849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303285
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: