MEDICARE: SHARONA MALLACH ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2505	MA

General Provider Information

NPI Number	:	1629714290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARONA MALLACH ATC

Provider Business Mailing Address
First Line	:	50 SUNSET LN
Second Line	:
City	:	PAXTON
State	:	MA
Zip	:	01612-1106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 SUNSET LN
Second Line	:
City	:	PAXTON
State	:	MA
Zip	:	01612-1106
Country	:	US
Telephone Number	:	508-849-3595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	05/06/2022

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Directions to “ SHARONA MALLACH ATC” Practice Location

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