Provider Demographics
NPI:1922390541
Name:MALLAMUD, MICHELLE ANNE (ADULT NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANNE
Last Name:MALLAMUD
Suffix:
Gender:F
Credentials:ADULT NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANNE
Other - Last Name:DOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3604
Mailing Address - Country:US
Mailing Address - Phone:251-753-2980
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:646-422-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305634363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1922390541OtherNPI