Provider Demographics
NPI:1578035861
Name:MALLORIS, TONI SHAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:SHAE
Last Name:MALLORIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13615 N INDIAN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3436
Mailing Address - Country:US
Mailing Address - Phone:321-591-4496
Mailing Address - Fax:
Practice Address - Street 1:13695 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3230
Practice Address - Country:US
Practice Address - Phone:772-589-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily