Provider Demographics
NPI:1093365199
Name:MALAK, LISA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MALAK
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 EARL DR
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-6470
Mailing Address - Country:US
Mailing Address - Phone:732-996-6935
Mailing Address - Fax:
Practice Address - Street 1:129 ROUTE 37 W
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6435
Practice Address - Country:US
Practice Address - Phone:732-797-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00963300363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology