Provider Demographics
NPI:1962978882
Name:MALLOY, KIMBERLY (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W 172ND ST APT 5G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-1849
Mailing Address - Country:US
Mailing Address - Phone:917-757-7821
Mailing Address - Fax:
Practice Address - Street 1:115 W 172ND ST APT 5G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-1849
Practice Address - Country:US
Practice Address - Phone:917-757-7821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713152163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse