Healthcare Provider Details

I. General information

NPI: 1194265249
Provider Name (Legal Business Name): RAQUEL DESIREE MALLETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8559 N LINE CREEK PKWY
KANSAS CITY MO
64154-2100
US

IV. Provider business mailing address

10908 W 66TH ST APT 303
SHAWNEE KS
66203-3425
US

V. Phone/Fax

Practice location:
  • Phone: 816-468-2011
  • Fax:
Mailing address:
  • Phone: 816-315-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2016043316
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: