Provider Demographics
NPI:1073062782
Name:MULLIS, MALLORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MULLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-1306
Mailing Address - Country:US
Mailing Address - Phone:251-809-8439
Mailing Address - Fax:
Practice Address - Street 1:1301 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1306
Practice Address - Country:US
Practice Address - Phone:251-809-8439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1168363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant