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General NPI Number Information
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NPI Number | 1588082911
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Entity Type | Individual
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Provider Name | TISHA MALLON L.AC., DIPL.AC.
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Gender | Female
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Dates
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Enumeration Date | 04/02/2014
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Last Update Date | 12/18/2019
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Provider Practice Location Address
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Address Line | 21 TAMAL VISTA BLVD
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City | CORTE MADERA
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State | CA
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Zip | 94925-1130
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Country | US
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Telephone | 415-378-3039
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Fax |
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Provider Business Mailing Address
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Address Line | 56 BELLE AVE
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City | FAIRFAX
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State | CA
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Zip | 94930-1727
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Country | US
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Telephone | 415-378-3039
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC 4302
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License Number State | CA
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