Healthcare Provider Details

I. General information

NPI: 1407611643
Provider Name (Legal Business Name): KALISTA T MALETTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 W 4TH NORTH ST
SUMMERVILLE SC
29483-6541
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 843-873-0681
  • Fax:
Mailing address:
  • Phone: 763-348-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5548
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: