Provider Demographics
NPI:1396363826
Name:OSTBERG, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:OSTBERG
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 1:7224 PACIFIC HWY E
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354
Mailing Address - Country:US
Mailing Address - Phone:253-205-0175
Mailing Address - Fax:
Practice Address - Street 1:7224 PACIFIC HWY E
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354
Practice Address - Country:US
Practice Address - Phone:253-205-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60277089163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health