Provider Demographics
NPI:1275380636
Name:MALLARD, CHARLOTTE MARY
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:MARY
Last Name:MALLARD
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 1:292 ASHLEE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-1138
Mailing Address - Country:US
Mailing Address - Phone:209-879-9570
Mailing Address - Fax:
Practice Address - Street 1:292 ASHLEE AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOUSE
Practice Address - State:CA
Practice Address - Zip Code:95391-1138
Practice Address - Country:US
Practice Address - Phone:209-879-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant