Provider Demographics
NPI:1811094493
Name:MALLOY, ELLEN THERESE (RN,NP)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:THERESE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:RN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 DARVANY DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-1614
Mailing Address - Country:US
Mailing Address - Phone:214-351-2356
Mailing Address - Fax:214-426-2231
Practice Address - Street 1:2922 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:BUILDING B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2321
Practice Address - Country:US
Practice Address - Phone:214-426-3645
Practice Address - Fax:214-426-2231
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX435024363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX435024OtherRN LICENSE NUMBER
TX86N596Medicare ID - Type UnspecifiedPROVIDER
TX435024OtherRN LICENSE NUMBER