Provider Information for 1053965202
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DIONETTA CHRISTINE MALLORY
Sex: Female
NPI: 1053965202
Last Updated: 2019-07-26
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1053965202 | ||||||||||||||
| Enumeration Date | 2019-07-26 | ||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||
| Sole Proprietor | YES | ||||||||||||||
| Status | Active | ||||||||||||||
| Mailing Address | 2501 N CALIFORNIA ST STOCKTON, CA 95204-5501 United States Phone: 209-620-5358 | Fax: | ||||||||||||||
| Primary Practice Address | 2510 N CALIFORNIA ST STOCKTON, CA 95204-5502 United States Phone: | Fax: | ||||||||||||||
| Secondary Practice Address(es) | 2510 N CALIFORNIA ST | ||||||||||||||
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