Most Relevant Information
Provider Data
| NPI Number: | 1003410408 |
| Provider Name: | TISHA DAWN MALLOW |
| Entity Type: | Individual |
| Taxonomy Code: | 3747P1801X |
| Specialty: | Technician |
| License Number: |
Most Important Dates
| Enumeration Date: | 11/25/2020 |
| Last Updated: | 10/02/2023 |
Provider Practice Location
8 N SPRING ST
BUCKHANNON
WV
262012720
Practice Location Phone/Fax
| Phone: | 3044720395 |
| Fax: | 3044712488 |
Provider Mailing Location
101 CABOOSE DRIVE
HARMAN
WV
26270
Provider Mailing Phone/Fax
| Phone: | 3047045479 |
| Fax: | 3044712488 |