Provider Demographics
NPI:1154820348
Name:MALLETT, MICHELLE M (ATC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:MALLETT
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BENNETT WAY APT 20
Mailing Address - Street 2:
Mailing Address - City:NEWMARKET
Mailing Address - State:NH
Mailing Address - Zip Code:03857-2363
Mailing Address - Country:US
Mailing Address - Phone:605-868-4507
Mailing Address - Fax:
Practice Address - Street 1:145 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824-3572
Practice Address - Country:US
Practice Address - Phone:605-868-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-02
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer