1679719819 NPI number — MS. DANA ELAINE MALLOY RN-FNP

Table of content: MS. DANA ELAINE MALLOY RN-FNP (NPI 1679719819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679719819 NPI number — MS. DANA ELAINE MALLOY RN-FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLOY
Provider First Name:
DANA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN-FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCRARY
Provider Other First Name:
DANA
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679719819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 SUMMERWOOD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AIKEN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29803-7704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-649-5300
Provider Business Mailing Address Fax Number:
803-649-0056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 SUMMERWOOD WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AIKEN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29803-7704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-649-5300
Provider Business Practice Location Address Fax Number:
803-649-0056
Provider Enumeration Date:
12/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  4057 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 4057 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 582366418 . This is a "TAX ID" identifier . This identifiers is of the category "OTHER".




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