Provider Demographics
NPI:1316118169
Name:MALAMISURA, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MALAMISURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111B SANDERS LANE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-9278
Mailing Address - Country:US
Mailing Address - Phone:276-326-3611
Mailing Address - Fax:276-322-2850
Practice Address - Street 1:111B SANDERS LANE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-9278
Practice Address - Country:US
Practice Address - Phone:276-326-3611
Practice Address - Fax:276-322-2850
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-20
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007211Medicaid