Provider Demographics
NPI:1376328906
Name:MALLOCH, CAROLE ANNE (DNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:ANNE
Last Name:MALLOCH
Suffix:
Gender:F
Credentials:DNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SALEM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3313
Mailing Address - Country:US
Mailing Address - Phone:207-891-9551
Mailing Address - Fax:
Practice Address - Street 1:269 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1314
Practice Address - Country:US
Practice Address - Phone:781-581-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2326260363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health