Provider Demographics
NPI:1316253818
Name:MALLOY, LISA CAREY (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CAREY
Last Name:MALLOY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 MENDON ST
Practice Address - Street 2:
Practice Address - City:HOPEDALE
Practice Address - State:MA
Practice Address - Zip Code:01747
Practice Address - Country:US
Practice Address - Phone:508-482-5401
Practice Address - Fax:508-482-5402
Is Sole Proprietor?:No
Enumeration Date:2010-08-23
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN285026363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner