Provider Demographics
NPI:1154376291
Name:MALLON, EMILY SAMANTHA (DC)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:SAMANTHA
Last Name:MALLON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 FOUNDERS WAY
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1102
Mailing Address - Country:US
Mailing Address - Phone:517-285-0417
Mailing Address - Fax:
Practice Address - Street 1:15630 N PRESTON HWY
Practice Address - Street 2:
Practice Address - City:BRUCETON MILLS
Practice Address - State:WV
Practice Address - Zip Code:26525-7036
Practice Address - Country:US
Practice Address - Phone:517-285-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010671111N00000X
WV895111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015448Medicaid
WVAM4262961Medicare PIN