Provider Demographics
NPI:1467024810
Name:MACKLIN, MALLORI V
Entity Type:Individual
Prefix:
First Name:MALLORI
Middle Name:V
Last Name:MACKLIN
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 1:2208 SAN LEANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5957
Mailing Address - Country:US
Mailing Address - Phone:510-483-6715
Mailing Address - Fax:510-483-6719
Practice Address - Street 1:2208 SAN LEANDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5957
Practice Address - Country:US
Practice Address - Phone:510-483-6715
Practice Address - Fax:510-483-6719
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program