Provider Demographics
NPI:1932643947
Name:MALLOY-CRAIG, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MALLOY-CRAIG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1917
Mailing Address - Country:US
Mailing Address - Phone:856-498-5433
Mailing Address - Fax:856-582-4400
Practice Address - Street 1:110 MARTER AVE STE 102
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3124
Practice Address - Country:US
Practice Address - Phone:856-235-6565
Practice Address - Fax:856-235-6566
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR14819100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily