Provider Demographics
NPI:1447070909
Name:VICEDOMINI, MALLORY (PA)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:VICEDOMINI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5025
Mailing Address - Country:US
Mailing Address - Phone:866-467-1770
Mailing Address - Fax:
Practice Address - Street 1:1057 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5025
Practice Address - Country:US
Practice Address - Phone:866-467-1770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant