Provider Demographics
NPI:1629783964
Name:MALAN, COREY KYLE
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:KYLE
Last Name:MALAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 STATE ST APT 8K
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3140
Mailing Address - Country:US
Mailing Address - Phone:860-977-2450
Mailing Address - Fax:
Practice Address - Street 1:392 STATE ST APT 8K
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3140
Practice Address - Country:US
Practice Address - Phone:860-977-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily