Provider Demographics
NPI:1265881015
Name:MALLOY, FAITH MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:MARIE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:MARIE
Other - Last Name:LEMIEUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3041
Practice Address - Country:US
Practice Address - Phone:980-308-0141
Practice Address - Fax:980-308-0140
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363AM0700X
NC0010-09656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical