Provider Demographics
NPI:1073669784
Name:MALLALIEU, JESSIE E (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:E
Last Name:MALLALIEU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4384
Mailing Address - Country:US
Mailing Address - Phone:301-698-2424
Mailing Address - Fax:
Practice Address - Street 1:63 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE B
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4384
Practice Address - Country:US
Practice Address - Phone:301-698-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant