Provider Demographics
NPI:1649564964
Name:MALLEY, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:MALLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 PETROLEUM PKWY
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-8020
Mailing Address - Country:US
Mailing Address - Phone:337-465-4600
Mailing Address - Fax:
Practice Address - Street 1:863 TUNICA DR E
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-3076
Practice Address - Country:US
Practice Address - Phone:318-717-1175
Practice Address - Fax:210-924-4113
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA7387363A00000X
LA311571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286422501Medicaid
TX286422501Medicaid