Provider Demographics
NPI:1225186588
Name:MALLIA, MARGUERITE H
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:H
Last Name:MALLIA
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 1:303 STRATHMORE DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-1551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5075 W SENECATPKE
Practice Address - Street 2:VAN DUYN HOME & HOSPITAL
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2292
Practice Address - Country:US
Practice Address - Phone:315-435-5511
Practice Address - Fax:315-435-5520
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303417-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF303417-1OtherNYS NURSE PRACT LICENSE