Provider Demographics
NPI:1609081116
Name:MALKIEL, MARY BERG (RN LAC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:BERG
Last Name:MALKIEL
Suffix:
Gender:F
Credentials:RN LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20703
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-3703
Mailing Address - Country:US
Mailing Address - Phone:303-807-1624
Mailing Address - Fax:
Practice Address - Street 1:972 W DILLON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-9448
Practice Address - Country:US
Practice Address - Phone:303-955-7226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO883171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist