Provider Demographics
NPI:1417551565
Name:MARANTO, MALLORY NICOLE (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:NICOLE
Last Name:MARANTO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HARVEST BEND DR
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4574
Mailing Address - Country:US
Mailing Address - Phone:972-762-0625
Mailing Address - Fax:
Practice Address - Street 1:1650 REPUBLIC PKWY STE 120
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6916
Practice Address - Country:US
Practice Address - Phone:972-285-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1010447363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics