Provider Demographics
NPI:1437659513
Name:MALLOY, SUSAN MORTON
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MORTON
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 1:2029 S COUNTY LINE AVE
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010-9454
Mailing Address - Country:US
Mailing Address - Phone:405-922-6587
Mailing Address - Fax:
Practice Address - Street 1:1311 N LOTTIE AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-2051
Practice Address - Country:US
Practice Address - Phone:405-600-3103
Practice Address - Fax:405-605-8120
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program