Provider Demographics
NPI:1033719596
Name:O'BRIEN, MALLORY
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:710 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-3143
Mailing Address - Country:US
Mailing Address - Phone:865-425-8800
Mailing Address - Fax:
Practice Address - Street 1:710 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3143
Practice Address - Country:US
Practice Address - Phone:865-425-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN230639163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse