Provider Demographics
NPI:1952984072
Name:MALLOY, HEATHER F
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:F
Last Name:MALLOY
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 1:810 LAKE CAROLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-5315
Mailing Address - Country:US
Mailing Address - Phone:540-645-8936
Mailing Address - Fax:
Practice Address - Street 1:810 LAKE CAROLINE DR
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-5315
Practice Address - Country:US
Practice Address - Phone:540-645-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
7578-7643-0457OtherNATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS
2000053207OtherATC BOC NUMBER