Provider Demographics
NPI:1598191918
Name:MALLON, AMBERLY MICHELE (MED, LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:AMBERLY
Middle Name:MICHELE
Last Name:MALLON
Suffix:
Gender:F
Credentials:MED, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11130 PARKVIEW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1735
Mailing Address - Country:US
Mailing Address - Phone:614-946-5269
Mailing Address - Fax:
Practice Address - Street 1:11130 PARKVIEW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1735
Practice Address - Country:US
Practice Address - Phone:614-946-5269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002180A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer