Provider Demographics
NPI:1124411749
Name:WHITE, MALLORY DAYLE (APRN, CNP-FAMILY)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:DAYLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:APRN, CNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7915
Mailing Address - Country:US
Mailing Address - Phone:918-215-5100
Mailing Address - Fax:918-215-5105
Practice Address - Street 1:514 PLAZA CT
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7915
Practice Address - Country:US
Practice Address - Phone:918-215-5100
Practice Address - Fax:918-215-5105
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK92345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK434557YMSDOtherMEDICARE
OK200599040AMedicaid