Provider Demographics
NPI:1871055350
Name:GAVIGAN, MALIA S (APRN)
Entity type:Individual
Prefix:
First Name:MALIA
Middle Name:S
Last Name:GAVIGAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MALIA
Other - Middle Name:S
Other - Last Name:FLORES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-1771
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3585
Practice Address - Country:US
Practice Address - Phone:321-868-5871
Practice Address - Fax:321-868-5852
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001047208M00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102499500Medicaid
FLL8207OtherMEDICARE