Provider Demographics
NPI:1093365199
Name:MALAK, LISA (AGNP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MALAK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EARL DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6470
Mailing Address - Country:US
Mailing Address - Phone:732-996-6935
Mailing Address - Fax:
Practice Address - Street 1:106 BRIDGE AVE STE 6
Practice Address - Street 2:
Practice Address - City:BAY HEAD
Practice Address - State:NJ
Practice Address - Zip Code:08742-5073
Practice Address - Country:US
Practice Address - Phone:732-996-6935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00963300363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner