Provider Demographics
NPI:1730391194
Name:MALLETT, REBECCA LEE (DO)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:LEE
Last Name:MALLETT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:LEE
Other - Last Name:BRUNDIGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:7404 W H AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-8586
Mailing Address - Country:US
Mailing Address - Phone:269-372-8233
Mailing Address - Fax:269-375-9662
Practice Address - Street 1:7404 W H AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-8586
Practice Address - Country:US
Practice Address - Phone:269-372-8233
Practice Address - Fax:269-375-9662
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine