Provider Demographics
NPI:1205875200
Name:MAALA, CLARICE (NP)
Entity type:Individual
Prefix:MS
First Name:CLARICE
Middle Name:
Last Name:MAALA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 WAYNE AVE
Mailing Address - Street 2:MONTEFIORE MEDICAL CENTER/ DEPARTMENT OF HEMATOLOGY
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2509
Mailing Address - Country:US
Mailing Address - Phone:718-920-6310
Mailing Address - Fax:
Practice Address - Street 1:3411 WAYNE AVE
Practice Address - Street 2:MONTEFIORE MEDICAL CENTER/ DEPARTMENT OF HEMATOLOGY
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2509
Practice Address - Country:US
Practice Address - Phone:718-920-6310
Practice Address - Fax:718-882-8698
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340561363LG0600X
NY303709363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02685812Medicaid
NY1369G1Medicare ID - Type Unspecified