Provider Demographics
NPI:1912328238
Name:MALLIA, AGNES (RN)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:MALLIA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 PELHAM RD
Mailing Address - Street 2:UNIT 7
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4010
Mailing Address - Country:US
Mailing Address - Phone:937-610-8771
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-350-8423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-05
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC220301163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse