Provider Demographics
NPI:1164188900
Name:HOGAN, MALLORIE (FNP-BC)
Entity Type:Individual
Prefix:MISS
First Name:MALLORIE
Middle Name:
Last Name:HOGAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10531 SILVERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-5533
Mailing Address - Country:US
Mailing Address - Phone:916-662-0020
Mailing Address - Fax:
Practice Address - Street 1:1631 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3820
Practice Address - Country:US
Practice Address - Phone:916-250-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018019363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty