Provider Demographics
NPI:1598370041
Name:MALLETTE, IESHA L (NP)
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:L
Last Name:MALLETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13304 LEESVILLE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-5206
Mailing Address - Country:US
Mailing Address - Phone:919-845-5276
Mailing Address - Fax:
Practice Address - Street 1:13304 LEESVILLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-5206
Practice Address - Country:US
Practice Address - Phone:919-845-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC190522163W00000X
NC5013679363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC052019OtherN/A