Provider Demographics
NPI:1376422139
Name:GRANI, MALLORY JENE (APRN, CNP, PMHNP-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JENE
Last Name:GRANI
Suffix:
Gender:F
Credentials:APRN, CNP, PMHNP-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:JENE
Other - Last Name:HALLING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12 W LAKE ST
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1817
Mailing Address - Country:US
Mailing Address - Phone:218-254-0101
Mailing Address - Fax:
Practice Address - Street 1:12 W LAKE ST
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719-1817
Practice Address - Country:US
Practice Address - Phone:218-254-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND200991363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty