Provider Demographics
NPI:1790443174
Name:MALLETT, ESTINE MICHELLE
Entity Type:Individual
Prefix:
First Name:ESTINE
Middle Name:MICHELLE
Last Name:MALLETT
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 1:621 GREEN MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:OVILLA
Mailing Address - State:TX
Mailing Address - Zip Code:75154-1474
Mailing Address - Country:US
Mailing Address - Phone:870-489-2692
Mailing Address - Fax:
Practice Address - Street 1:801 W IRVING BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-2845
Practice Address - Country:US
Practice Address - Phone:870-489-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor