Provider Demographics
NPI:1477292779
Name:EDWARDS, MALLORY (DNP)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 BALMER ST BLDG 570
Mailing Address - Street 2:
Mailing Address - City:HILL AIR FORCE BASE
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER ST BLDG 570
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-586-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022010300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty