Provider Demographics
NPI:1407419450
Name:MALLETT, VICTORIA JADE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:JADE
Last Name:MALLETT
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 1:36 LUCY LN
Mailing Address - Street 2:
Mailing Address - City:CENTER RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72027-8439
Mailing Address - Country:US
Mailing Address - Phone:501-208-7233
Mailing Address - Fax:
Practice Address - Street 1:4304 ANDREWS HWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4824
Practice Address - Country:US
Practice Address - Phone:432-520-3020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1311710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist