Provider Demographics
NPI:1851578520
Name:O'MALLEY, MAURA (ANP)
Entity Type:Individual
Prefix:MS
First Name:MAURA
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 RICHMOND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5882
Mailing Address - Country:US
Mailing Address - Phone:718-816-6440
Mailing Address - Fax:
Practice Address - Street 1:1050 CLOVE ROAD
Practice Address - Street 2:STATEN ISLAND PHYSICIAN PRACTICE
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-5509
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3749
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304408-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02990370Medicaid
NY02990370Medicaid