Provider Demographics
NPI:1841287430
Name:MALLICONE, WESLEY R (MS, ATC)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:R
Last Name:MALLICONE
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 FORT ST
Mailing Address - Street 2:APT.# 6
Mailing Address - City:SHIPPENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17257-1455
Mailing Address - Country:US
Mailing Address - Phone:717-816-3355
Mailing Address - Fax:
Practice Address - Street 1:1871 OLD MAIN DR
Practice Address - Street 2:
Practice Address - City:SHIPPENSBURG
Practice Address - State:PA
Practice Address - Zip Code:17257-2200
Practice Address - Country:US
Practice Address - Phone:717-477-1749
Practice Address - Fax:717-477-4070
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002265A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer