Healthcare Provider Details

I. General information

NPI: 1598414757
Provider Name (Legal Business Name): KIMBERLY E MALLORY BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 03/23/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

19199 APPOLINE ST
DETROIT MI
48235-1214
US

V. Phone/Fax

Practice location:
  • Phone: 313-324-8900
  • Fax:
Mailing address:
  • Phone: 248-403-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: