Provider Demographics
NPI:1871922773
Name:MALLICK, FARZANA
Entity type:Individual
Prefix:
First Name:FARZANA
Middle Name:
Last Name:MALLICK
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 1:16515 CHAPIN CT
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-1904
Mailing Address - Country:US
Mailing Address - Phone:917-783-8621
Mailing Address - Fax:718-725-6411
Practice Address - Street 1:16515 CHAPIN CT
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1904
Practice Address - Country:US
Practice Address - Phone:917-783-8621
Practice Address - Fax:718-725-6411
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY759935174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator