Basic Information
| Provider Information | |||||||||
| NPI: | 1831526201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLOZZI | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPN. AE-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 825 CHALKSTONE AVE | ||||||||
| Address2: | N. CAMPUS BUSINESS OFFICE, ATTN: R. SOARES | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014562525 | ||||||||
| FaxNumber: | 4014566742 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 PEACE ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029071510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014564321 | ||||||||
| FaxNumber: | 4014564369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2013 | ||||||||
| LastUpdateDate: | 10/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN08585 | RI | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | LPN08585 | 01 | RI | LICENSE NUMBER | OTHER |