Provider Demographics
NPI:1295225357
Name:HARRIS, MALLORY KAY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAY
Last Name:HARRIS
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 1:300 S 8TH ST STE 505E
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2460
Mailing Address - Country:US
Mailing Address - Phone:270-753-3131
Mailing Address - Fax:
Practice Address - Street 1:817 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1648
Practice Address - Country:US
Practice Address - Phone:270-873-8200
Practice Address - Fax:270-873-8201
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2108DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist