Basic Information
| Provider Information | |||||||||
| NPI: | 1063656452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALM | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 25TH AVE S | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124552008 | ||||||||
| FaxNumber: | 6124552009 | ||||||||
| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVE S | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528350750 | ||||||||
| FaxNumber: | 9528350662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2009 | ||||||||
| LastUpdateDate: | 04/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | Y |
No ID Information.