Provider Demographics
NPI:1356816359
Name:NOTTENKAMPER, MALLORY MOZLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MOZLEY
Last Name:NOTTENKAMPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12626 DOMINION DR
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-7704
Mailing Address - Country:US
Mailing Address - Phone:251-228-2389
Mailing Address - Fax:
Practice Address - Street 1:188 HOSPITAL DR STE 202
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2038
Practice Address - Country:US
Practice Address - Phone:251-990-1922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-1386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine