Provider Demographics
NPI:1487209474
Name:MALONEY, MITSUKO MIMI
Entity Type:Individual
Prefix:
First Name:MITSUKO
Middle Name:MIMI
Last Name:MALONEY
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 1:8124 ROSEBURY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60517-7736
Mailing Address - Country:US
Mailing Address - Phone:630-207-6879
Mailing Address - Fax:
Practice Address - Street 1:8124 ROSEBURY AVE
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-7736
Practice Address - Country:US
Practice Address - Phone:630-207-6879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider