Provider Demographics
NPI:1861445447
Name:MALLOY, JACQUELINE A (ARNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:MALLOY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 WATERFORD ESTATES MNR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9422
Mailing Address - Country:US
Mailing Address - Phone:770-704-1995
Mailing Address - Fax:706-632-3585
Practice Address - Street 1:101 RIVERSTONE VIS
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6648
Practice Address - Country:US
Practice Address - Phone:706-258-4400
Practice Address - Fax:706-632-3585
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9164727363L00000X
GAARNP 103102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I509126Medicare PIN
FLY083CZMedicare ID - Type Unspecified
FLQ55419Medicare UPIN