Provider Demographics
NPI:1336510403
Name:TIMM, MALLORY MAE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MAE
Last Name:TIMM
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 1:325 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1325
Mailing Address - Country:US
Mailing Address - Phone:920-731-7310
Mailing Address - Fax:
Practice Address - Street 1:325 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1325
Practice Address - Country:US
Practice Address - Phone:920-731-7310
Practice Address - Fax:920-733-3050
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2376-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant