Provider Demographics
NPI:1134309669
Name:MALLON, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MALLON
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 1:412 LIBBIE AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2659
Mailing Address - Country:US
Mailing Address - Phone:804-282-8082
Mailing Address - Fax:804-282-9082
Practice Address - Street 1:412 LIBBIE AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2659
Practice Address - Country:US
Practice Address - Phone:804-282-8082
Practice Address - Fax:804-282-9082
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167392363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal