Healthcare Provider Details

I. General information

NPI: 1689202111
Provider Name (Legal Business Name): KIMBERLY MALMBORG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 POND PARK RD STE 102
HINGHAM MA
02043-4354
US

IV. Provider business mailing address

10 CLIFF ST APT 3
QUINCY MA
02169-1460
US

V. Phone/Fax

Practice location:
  • Phone: 781-337-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3553
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: