Provider Demographics
NPI:1235877366
Name:MALLERY, LAURIE HERZIG
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:HERZIG
Last Name:MALLERY
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 1:5841 CHAIN ROCK DRIVE
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NOVA SCOTIA
Mailing Address - Zip Code:B3H1A2
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 NOSTRAND AVE # 1086
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4500
Practice Address - Country:US
Practice Address - Phone:902-471-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316843207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine