Provider Demographics
NPI:1275560872
Name:MALIK, CONSTANCE W (MA, RD, LDN, CDE)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:W
Last Name:MALIK
Suffix:
Gender:F
Credentials:MA, RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4137
Mailing Address - Country:US
Mailing Address - Phone:813-949-8459
Mailing Address - Fax:
Practice Address - Street 1:JAMES A. HALEY VA HOSPITAL (120)
Practice Address - Street 2:13000 BRUCE B. DOWNS BLVD.
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND000668133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
10742OtherREGISTERED DIETITIAN