Provider Demographics
NPI:1417267543
Name:MALLORY, KATHLEEN NAVAR (RN WCC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:NAVAR
Last Name:MALLORY
Suffix:
Gender:F
Credentials:RN WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1133
Mailing Address - Street 2:
Mailing Address - City:LA LUZ
Mailing Address - State:NM
Mailing Address - Zip Code:88337-1133
Mailing Address - Country:US
Mailing Address - Phone:575-921-3305
Mailing Address - Fax:
Practice Address - Street 1:1 ABALONE LOOP
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:575-464-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR62638163W00000X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163W00000XNursing Service ProvidersRegistered Nurse