Provider Demographics
NPI:1316404700
Name:RIDDLE, MALLORY LYNN (DPT)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:LYNN
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:LYNN
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:535 MCDERMITT RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1616
Mailing Address - Country:US
Mailing Address - Phone:901-832-0040
Mailing Address - Fax:
Practice Address - Street 1:535 MCDERMITT RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1616
Practice Address - Country:US
Practice Address - Phone:901-832-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10941225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist