Provider Demographics
NPI:1285856492
Name:MALLIK, DEBASHREE (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBASHREE
Middle Name:
Last Name:MALLIK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:800-242-1131
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:3510 N CAUSEWAY BLVD
Practice Address - Street 2:SUITE 404
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-3531
Practice Address - Country:US
Practice Address - Phone:504-779-5515
Practice Address - Fax:504-779-5568
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA103829367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A4456766Medicare PIN