Healthcare Provider Details

I. General information

NPI: 1497348064
Provider Name (Legal Business Name): MS. NANCY LYNN MALLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2021
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 N JOHNSON AVE STE 111
EL CAJON CA
92020-1649
US

IV. Provider business mailing address

5565 LA JOLLA MESA DR
LA JOLLA CA
92037-7718
US

V. Phone/Fax

Practice location:
  • Phone: 619-440-4801
  • Fax: 619-442-1592
Mailing address:
  • Phone: 619-648-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: