Provider Demographics
NPI:1255682381
Name:MALLORY, EDNA ELAINE (NP-C)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:ELAINE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:E
Other - Middle Name:ELAINE
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:35 ELY CALLAWAY ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:31833
Mailing Address - Country:US
Mailing Address - Phone:706-885-1401
Mailing Address - Fax:
Practice Address - Street 1:100 DUPLAINVILLE RD
Practice Address - Street 2:
Practice Address - City:THE ROCK
Practice Address - State:GA
Practice Address - Zip Code:30285-2492
Practice Address - Country:US
Practice Address - Phone:706-648-5915
Practice Address - Fax:706-648-5919
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN185828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily