Provider Demographics
NPI:1073262937
Name:CROLEY, MALLORY RENEE'
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:RENEE'
Last Name:CROLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 W MOUNTAIN VIEW RD APT 1506
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2533
Mailing Address - Country:US
Mailing Address - Phone:704-783-5386
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26506-1200
Practice Address - Country:US
Practice Address - Phone:304-598-0430
Practice Address - Fax:304-598-4890
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2022-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program