1407846801 NPI number — MARY LEANORA MALLERNEE

Table of content: MARY LEANORA MALLERNEE (NPI 1407846801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407846801 NPI number — MARY LEANORA MALLERNEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLERNEE
Provider First Name:
MARY
Provider Middle Name:
LEANORA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407846801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHIPROCK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87420-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-368-6401
Provider Business Mailing Address Fax Number:
505-368-6431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US HWY 491 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPROCK
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-368-6401
Provider Business Practice Location Address Fax Number:
505-368-6431
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R49684 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R49684 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42979323 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 99777533 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 803735 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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