Provider Demographics
NPI:1619300654
Name:MALAVE, VIVIAN RAEL (ATC, PA-C)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:RAEL
Last Name:MALAVE
Suffix:
Gender:F
Credentials:ATC, PA-C
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:RAEL
Other - Last Name:RIVERA ROMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6416 OLD WINTER GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1348
Mailing Address - Country:US
Mailing Address - Phone:407-751-7288
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:14075 TOWN LOOP BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6132
Practice Address - Country:US
Practice Address - Phone:407-438-5858
Practice Address - Fax:407-438-7172
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35592255A2300X
FLPA9111563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer