Provider Demographics
NPI:1477191849
Name:MALLON, MITCH
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:MALLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E HANOVER AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-2011
Mailing Address - Country:US
Mailing Address - Phone:973-998-7210
Mailing Address - Fax:
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-971-8457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00980600364SN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SN0000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistNeonatal