Provider Demographics
NPI:1245232453
Name:MALLOY, TERRY L (RCNS MSN)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:L
Last Name:MALLOY
Suffix:
Gender:F
Credentials:RCNS MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1961
Mailing Address - Country:US
Mailing Address - Phone:906-632-1800
Mailing Address - Fax:906-632-2199
Practice Address - Street 1:560 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1961
Practice Address - Country:US
Practice Address - Phone:906-632-1800
Practice Address - Fax:906-632-2199
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704102901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP09000001Medicare ID - Type Unspecified
MIQ33902Medicare UPIN