Provider Demographics
NPI:1326132580
Name:MALLOY, GAIL BERKSON (PHD RN CS)
Entity Type:Individual
Prefix:DR
First Name:GAIL
Middle Name:BERKSON
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PHD RN CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570
Mailing Address - Country:US
Mailing Address - Phone:516-678-1928
Mailing Address - Fax:
Practice Address - Street 1:110 JERICHO TPK
Practice Address - Street 2:SUITE 102
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-2019
Practice Address - Country:US
Practice Address - Phone:516-352-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135733364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
62415007OtherMULTIPLAN
5926155OtherAETNA
Y032293OtherTRICARE CHAMPUS
7493846002OtherGHI VALUE OPTIONS
S23959Medicare UPIN
NYR01151Medicare ID - Type Unspecified