Provider Demographics
NPI:1316341878
Name:MALLA, NANDINI (CCC-SLP)
Entity type:Individual
Prefix:
First Name:NANDINI
Middle Name:
Last Name:MALLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 35TH ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4509
Mailing Address - Country:US
Mailing Address - Phone:972-207-1578
Mailing Address - Fax:
Practice Address - Street 1:200 S 8TH AVE E
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-4762
Practice Address - Country:US
Practice Address - Phone:641-792-7440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA073364235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist