Provider Demographics
NPI:1366044844
Name:MEAGHER, MALLORY MARGARET
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARGARET
Last Name:MEAGHER
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 1:101 YORKTOWN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7663
Mailing Address - Country:US
Mailing Address - Phone:678-593-9016
Mailing Address - Fax:
Practice Address - Street 1:4000 SHAKERAG HL STE 201
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4047
Practice Address - Country:US
Practice Address - Phone:770-486-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10051363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical