Provider Demographics
NPI:1578807178
Name:MALLARI, RIA ANNE GRETCHEN REAL (RN)
Entity Type:Individual
Prefix:MRS
First Name:RIA ANNE
Middle Name:GRETCHEN REAL
Last Name:MALLARI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 VAN LOON ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4225
Mailing Address - Country:US
Mailing Address - Phone:347-515-9477
Mailing Address - Fax:
Practice Address - Street 1:5217 VAN LOON ST APT 3
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-4225
Practice Address - Country:US
Practice Address - Phone:347-515-9477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584674-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse