Provider Demographics
NPI:1205225273
Name:MALYSZ, MERIDITH LEWIS (CNP)
Entity Type:Individual
Prefix:
First Name:MERIDITH
Middle Name:LEWIS
Last Name:MALYSZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-2731
Practice Address - Fax:508-856-1786
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2275339363L00000X, 363LF0000X
RIAPRN00182363L00000X, 363L00000X
RIRN54086163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1205225273Medicaid
PW7090004048OtherMEDICARE GROUP PTAN
RI1205225273Medicaid