Provider Demographics
NPI:1134661440
Name:ROBERSON, MALLORY (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MAIN AVE SW
Mailing Address - Street 2:SUITE E
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-5299
Mailing Address - Country:US
Mailing Address - Phone:256-531-9213
Mailing Address - Fax:
Practice Address - Street 1:1701 MAIN AVE SW
Practice Address - Street 2:SUITE E
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-5299
Practice Address - Country:US
Practice Address - Phone:256-531-9213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-131922363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I505361Medicare PIN