Provider Demographics
NPI:1003379207
Name:HALLAHAN, MALISSA
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:HALLAHAN
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 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4408
Practice Address - Country:US
Practice Address - Phone:866-682-4842
Practice Address - Fax:877-435-6573
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-13
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-141039163WM0102X
CANP95013990363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn