Provider Demographics
NPI:1265030753
Name:CONNER, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:CONNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W FAYETTE ST STE 400
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2866
Mailing Address - Country:US
Mailing Address - Phone:315-937-3433
Mailing Address - Fax:315-937-3833
Practice Address - Street 1:739 IRVING AVE STE 340
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1605
Practice Address - Country:US
Practice Address - Phone:315-479-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2020011129363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health