Provider Demographics
NPI:1932172681
Name:MALLOY, PRISCILLA B (AP RN)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:B
Last Name:MALLOY
Suffix:
Gender:F
Credentials:AP RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-9300
Mailing Address - Fax:860-545-9301
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9300
Practice Address - Fax:860-545-9301
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTR32068163WP0200X
CT000209364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236007Medicaid
CTR32068OtherRN LICENSE
CT000209OtherAPRN
CT000209OtherAPRN