Provider Demographics
NPI:1790325413
Name:MALLARD, CAROLYNN
Entity Type:Individual
Prefix:
First Name:CAROLYNN
Middle Name:
Last Name:MALLARD
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 1:6149 1ST PL NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1511
Mailing Address - Country:US
Mailing Address - Phone:202-882-8128
Mailing Address - Fax:
Practice Address - Street 1:6149 1ST PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1511
Practice Address - Country:US
Practice Address - Phone:202-882-8128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant