Healthcare Provider Details

I. General information

NPI: 1255802377
Provider Name (Legal Business Name): MALLORY KATHRYN AYE NMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MALLORY AYE NMD

II. Dates (important events)

Enumeration Date: 12/16/2018
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E WALNUT ST STE 100
PASADENA CA
91106-1478
US

IV. Provider business mailing address

2322 ALTA ST
LOS ANGELES CA
90031-2846
US

V. Phone/Fax

Practice location:
  • Phone: 323-207-5953
  • Fax:
Mailing address:
  • Phone: 971-322-8682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number4219
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number18-1760
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1135
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: