Healthcare Provider Details

I. General information

NPI: 1669705802
Provider Name (Legal Business Name): LINDA MALONE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 FAIRFAX AVE 3RD FLOOR
NORFOLK VA
23507-2007
US

IV. Provider business mailing address

PO BOX 936
NORFOLK VA
23501-0936
US

V. Phone/Fax

Practice location:
  • Phone: 757-446-5915
  • Fax: 757-446-5089
Mailing address:
  • Phone: 757-446-5915
  • Fax: 757-446-5089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003091
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: