Provider Demographics
NPI:1013543388
Name:BOGGS, MALLORY ELIZABETH (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:BOGGS
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BLACKSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8808
Mailing Address - Country:US
Mailing Address - Phone:601-720-9845
Mailing Address - Fax:
Practice Address - Street 1:159 FOUNTAINS BLVD STE B
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6344
Practice Address - Country:US
Practice Address - Phone:601-859-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903821363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care