Provider Demographics
NPI:1780935346
Name:MALAVE, ITHAMAR
Entity type:Individual
Prefix:MRS
First Name:ITHAMAR
Middle Name:
Last Name:MALAVE
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 1:200 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2424
Mailing Address - Country:US
Mailing Address - Phone:631-727-3331
Mailing Address - Fax:
Practice Address - Street 1:50 WHEELER RD
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2154
Practice Address - Country:US
Practice Address - Phone:631-348-5112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY542565-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse