MEDICARE: MARGUERITE H MALLIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	F303417-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F303417-1	OTHER	NY	NYS NURSE PRACT LICENSE

General Provider Information

NPI Number	:	1225186588
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARGUERITE H MALLIA

Provider Business Mailing Address
First Line	:	303 STRATHMORE DR
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13207-1551
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5075 W SENECATPKE
Second Line	:	VAN DUYN HOME & HOSPITAL
City	:	SYRACUSE
State	:	NY
Zip	:	13215-2292
Country	:	US
Telephone Number	:	315-435-5511
Fax Number	:	315-435-5520

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	07/08/2007

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Directions to “ MARGUERITE H MALLIA ” Practice Location

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