Provider Demographics
NPI:1891776555
Name:MALONEY, JUDITH ANNE (ANP)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:ANNE
Last Name:MALONEY
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 1:228 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3615
Mailing Address - Country:US
Mailing Address - Phone:315-788-9849
Mailing Address - Fax:
Practice Address - Street 1:228 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3612
Practice Address - Country:US
Practice Address - Phone:315-788-9849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF303285363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF303285OtherLICENSE
NYP41950Medicare UPIN
CC9293Medicare ID - Type UnspecifiedMEDICARE
NYF303285OtherLICENSE