Provider Demographics
NPI:1497880256
Name:O'MALLEY, MARY ANN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CASTLE WAY
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-9471
Mailing Address - Country:US
Mailing Address - Phone:252-321-7985
Mailing Address - Fax:252-321-6004
Practice Address - Street 1:106 E VICTORIA CT STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5708
Practice Address - Country:US
Practice Address - Phone:252-321-6001
Practice Address - Fax:252-321-6004
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2352225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7210470Medicaid