Provider Demographics
NPI:1477229243
Name:NEELY, MALIK LAMONT
Entity Type:Individual
Prefix:
First Name:MALIK
Middle Name:LAMONT
Last Name:NEELY
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 1:3208 STAMFORD RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-3732
Mailing Address - Country:US
Mailing Address - Phone:757-232-6516
Mailing Address - Fax:
Practice Address - Street 1:4051 CEDAR LN STE C
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2003
Practice Address - Country:US
Practice Address - Phone:757-335-4987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide