MEDICARE: COREY KYLE MALAN

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	363LF0000X	Family Nurse Practitioner	11403	CT

General Provider Information

NPI Number	:	1629783964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY KYLE MALAN

Provider Business Mailing Address
First Line	:	119 FOREST HILL RD
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-4301
Country	:	US
Telephone Number	:	860-977-2450
Fax Number	:

Provider Business Practice Location Address
First Line	:	392 STATE ST APT 8K
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-3140
Country	:	US
Telephone Number	:	860-977-2450
Fax Number	:

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

Provider Enumeration Date	:	01/20/2023
Last Update Date	:	10/31/2024

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Directions to “ COREY KYLE MALAN ” Practice Location

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