Provider Demographics
NPI:1518521251
Name:WEATHERLY, MALLORY ANNE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:ANNE
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ANNE
Other - Last Name:WEIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-2719
Mailing Address - Country:US
Mailing Address - Phone:772-321-3160
Mailing Address - Fax:
Practice Address - Street 1:3450 11TH COURT
Practice Address - Street 2:SUITE 206
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960
Practice Address - Country:US
Practice Address - Phone:772-299-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00000Medicaid