Provider Demographics
NPI:1164634598
Name:NERY, NOMILINNE MALLARE (MD)
Entity Type:Individual
Prefix:DR
First Name:NOMILINNE
Middle Name:MALLARE
Last Name:NERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 OLD YORK RD APT B314
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-2215
Mailing Address - Country:US
Mailing Address - Phone:215-917-3381
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102332728 0001Medicaid
PA2152120OtherHIGHMARK BLUE SHIELD
PAP00765862OtherRR MEDICARE
PAP00765862OtherRR MEDICARE
PA162374ZDKTMedicare PIN