=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861445447
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE A. MALLOY ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 RIVERSTONE VIS
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-6648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-258-4400
-----------------------------------------------------
Fax | 706-632-3585
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 WATERFORD ESTATES MNR
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-704-1995
-----------------------------------------------------
Fax | 706-632-3585
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 9164727
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 80435
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1159783
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | ARNP 103102
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------