Provider Demographics
NPI:1801286240
Name:MALLA, SOBHA (RD, CSR)
Entity type:Individual
Prefix:
First Name:SOBHA
Middle Name:
Last Name:MALLA
Suffix:
Gender:F
Credentials:RD, CSR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CENTER GROVE RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-4453
Mailing Address - Country:US
Mailing Address - Phone:510-792-2652
Mailing Address - Fax:
Practice Address - Street 1:121 CENTER GROVE RD
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-4453
Practice Address - Country:US
Practice Address - Phone:315-834-2382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-23
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ931194133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal