Provider Demographics
NPI:1477811032
Name:MALI, KELLEY WACHTER (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:WACHTER
Last Name:MALI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-2036
Mailing Address - Country:US
Mailing Address - Phone:908-399-3506
Mailing Address - Fax:
Practice Address - Street 1:50 NEWARK AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1185
Practice Address - Country:US
Practice Address - Phone:973-429-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00280600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant