Provider Demographics
NPI:1235465576
Name:DRAKE, MALYNN THERESA (DC)
Entity Type:Individual
Prefix:DR
First Name:MALYNN
Middle Name:THERESA
Last Name:DRAKE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:DRAKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:72 ROUTE 27
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3986
Mailing Address - Country:US
Mailing Address - Phone:732-662-9901
Mailing Address - Fax:732-662-9904
Practice Address - Street 1:72 ROUTE 27
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3986
Practice Address - Country:US
Practice Address - Phone:732-662-9901
Practice Address - Fax:732-662-9904
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-31279111N00000X
NJ38MC00738900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ38MC00738900OtherLICENSE NUMBER