Provider Demographics
NPI:1437995784
Name:PRIVETTE MALAMALA, GRACE OLIVIA
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:OLIVIA
Last Name:PRIVETTE MALAMALA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13030 WARWICK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-8374
Mailing Address - Country:US
Mailing Address - Phone:757-746-4843
Mailing Address - Fax:
Practice Address - Street 1:13030 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-8374
Practice Address - Country:US
Practice Address - Phone:757-746-4843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-06
Last Update Date:2025-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002527224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant