Provider Demographics
NPI:1215420724
Name:MALLON, AUDREY JEAN (DPT)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JEAN
Last Name:MALLON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 S 700 E APT F
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2800
Mailing Address - Country:US
Mailing Address - Phone:541-490-4450
Mailing Address - Fax:
Practice Address - Street 1:590 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10851651-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist