Provider Demographics
NPI:1497348064
Name:MALLOW, NANCY LYNN
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LYNN
Last Name:MALLOW
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 1:5565 LA JOLLA MESA DR
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7718
Mailing Address - Country:US
Mailing Address - Phone:619-648-0203
Mailing Address - Fax:
Practice Address - Street 1:1365 N JOHNSON AVE STE 111
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1649
Practice Address - Country:US
Practice Address - Phone:619-440-4801
Practice Address - Fax:619-442-1592
Is Sole Proprietor?:No
Enumeration Date:2021-02-15
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101YA0400X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist