Provider Demographics
NPI:1457449258
Name:MALLORY, RONALD RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RAY
Last Name:MALLORY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 HOSPITAL CIR
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3102
Mailing Address - Country:US
Mailing Address - Phone:706-745-2111
Mailing Address - Fax:706-745-3114
Practice Address - Street 1:214 HOSPITAL CIR
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3102
Practice Address - Country:US
Practice Address - Phone:706-745-2111
Practice Address - Fax:706-745-3114
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR095938367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered