Provider Demographics
NPI:1669294948
Name:MALLOY, KATEASTA NICOLE (PTA)
Entity type:Individual
Prefix:
First Name:KATEASTA
Middle Name:NICOLE
Last Name:MALLOY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KATEASTA
Other - Middle Name:NICOLE
Other - Last Name:MALLOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:95 COLONIAL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:FORT ASHBY
Mailing Address - State:WV
Mailing Address - Zip Code:26719-6962
Mailing Address - Country:US
Mailing Address - Phone:301-876-8087
Mailing Address - Fax:
Practice Address - Street 1:95 COLONIAL HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:FORT ASHBY
Practice Address - State:WV
Practice Address - Zip Code:26719-6962
Practice Address - Country:US
Practice Address - Phone:301-876-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant