Provider Demographics
NPI:1336922723
Name:MALAN, BRIELLE
Entity Type:Individual
Prefix:
First Name:BRIELLE
Middle Name:
Last Name:MALAN
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 1:5533 S 1425 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5160
Mailing Address - Country:US
Mailing Address - Phone:801-648-5962
Mailing Address - Fax:
Practice Address - Street 1:2348 KIESEL AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1964
Practice Address - Country:US
Practice Address - Phone:801-528-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11187040-4701225700000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist