Provider Demographics
NPI:1639540420
Name:MALLARE, STACY S
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:S
Last Name:MALLARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10954 HILLTOP LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3780
Mailing Address - Country:US
Mailing Address - Phone:410-718-3213
Mailing Address - Fax:
Practice Address - Street 1:10954 HILLTOP LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3780
Practice Address - Country:US
Practice Address - Phone:410-718-3213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR186082363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health