Provider Demographics
NPI:1902498306
Name:MALLON, KIRSTEN LEIGH (LPTA)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:LEIGH
Last Name:MALLON
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8685 MAGNOLIA LN E
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:AL
Mailing Address - Zip Code:36544-6036
Mailing Address - Country:US
Mailing Address - Phone:251-644-4008
Mailing Address - Fax:
Practice Address - Street 1:1220 AZALEA RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-2859
Practice Address - Country:US
Practice Address - Phone:251-607-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55033225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant