Provider Demographics
NPI:1508282138
Name:MALLIK, DIANNE GRACE (LAC)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:GRACE
Last Name:MALLIK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:MISS
Other - First Name:DIANNE
Other - Middle Name:GRACE
Other - Last Name:MALIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:17218 BOCA RATON LN
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-1304
Mailing Address - Country:US
Mailing Address - Phone:802-734-3838
Mailing Address - Fax:
Practice Address - Street 1:2330 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2539
Practice Address - Country:US
Practice Address - Phone:858-208-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-06
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0000161171100000X
CAAC3885171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist