Provider Demographics
NPI:1275809741
Name:MALLORY, NICOLE CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:CHRISTINE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:300 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-6303
Mailing Address - Country:US
Mailing Address - Phone:732-923-7455
Mailing Address - Fax:732-923-7451
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-923-7455
Practice Address - Fax:732-923-7451
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10637200208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics