Provider Demographics
NPI:1033822911
Name:MALLOY, MICHELLE KATHLEEN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:MALLOY
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 1:4337 W SARAH ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-3837
Mailing Address - Country:US
Mailing Address - Phone:630-886-1450
Mailing Address - Fax:
Practice Address - Street 1:7223 BEVERLY BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-2500
Practice Address - Country:US
Practice Address - Phone:630-886-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-05
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19636171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist