Provider Demographics
NPI:1518209089
Name:BAKER, MALLORY CAMILLE
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:CAMILLE
Last Name:BAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MALLORY
Other - Middle Name:CAMILLE
Other - Last Name:FAULKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:741 PRESIDENT PL
Mailing Address - Street 2:STE 200
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6809
Mailing Address - Country:US
Mailing Address - Phone:615-369-9899
Mailing Address - Fax:
Practice Address - Street 1:550 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-852-4277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN55808207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics