Provider Demographics
NPI:1558520577
Name:MALLEN, CARRIE R
Entity Type:Individual
Prefix:MISS
First Name:CARRIE
Middle Name:R
Last Name:MALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1413
Mailing Address - Country:US
Mailing Address - Phone:201-525-1777
Mailing Address - Fax:201-525-0149
Practice Address - Street 1:370 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1413
Practice Address - Country:US
Practice Address - Phone:201-525-1777
Practice Address - Fax:201-525-0149
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00174800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical