Provider Demographics
NPI:1811490667
Name:RANDY V. MALLARI PLC
Entity type:Organization
Organization Name:RANDY V. MALLARI PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:V
Authorized Official - Last Name:MALLARI
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC, FNP-BC
Authorized Official - Phone:602-908-8580
Mailing Address - Street 1:14655 N 35TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-4605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16220 N SCOTTSDALE RD STE 300
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1798
Practice Address - Country:US
Practice Address - Phone:480-295-9977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363LP0808X
AZAL8771H3104A0625X, 3104A0630X, 323P00000X, 3104A0630X, 323P00000X
AZAL8842H3104A0625X, 3104A0630X, 323P00000X, 310400000X, 3104A0630X, 323P00000X
AZRN207973251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL8842HOtherARIZONA DEPARTMENT OF HEALTH SERVICES
AZAL8771HOtherARIZONA DEPARTMENT OF HEALTH SERVICES
AZRN207973OtherARIZONA STATE BOARD OF NURSING
AZAZCLDP81706OtherARIZONA SUPREME COURT
AZAL8771HOtherARIZONA DEPARTMENT OF HEALTH SERVICES