Provider Demographics
NPI:1285952929
Name:O'MALLEY, DEIDRE ANNE (BSN RN LAC)
Entity type:Individual
Prefix:
First Name:DEIDRE
Middle Name:ANNE
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:BSN RN LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95461-0687
Mailing Address - Country:US
Mailing Address - Phone:707-987-3442
Mailing Address - Fax:
Practice Address - Street 1:21128 CALISTOGA ST.
Practice Address - Street 2:SUITE A
Practice Address - City:MIDDLETOWN
Practice Address - State:CA
Practice Address - Zip Code:95461
Practice Address - Country:US
Practice Address - Phone:707-987-3442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-05
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC12238171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist