Provider Demographics
NPI:1053045203
Name:SMALLZE, MALLORY ANNE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:SMALLZE
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 1:13 DOROTHY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3303
Mailing Address - Country:US
Mailing Address - Phone:201-421-7757
Mailing Address - Fax:
Practice Address - Street 1:22-18 BROADWAY
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3016
Practice Address - Country:US
Practice Address - Phone:201-414-9840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01325700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner