Provider Demographics
NPI:1225775455
Name:MALLORY, NICOLE C (PHLEBOTOMIST)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:C
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1944 APPALOOSA MILL CIR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6616
Mailing Address - Country:US
Mailing Address - Phone:404-518-8006
Mailing Address - Fax:
Practice Address - Street 1:1944 APPALOOSA MILL CIR
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-6616
Practice Address - Country:US
Practice Address - Phone:404-518-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA753018246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty