Provider Demographics
NPI:1548561202
Name:WILLIAMS, MELODY MALLORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:MALLORY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:BETH
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76508-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 S 25TH ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-5227
Practice Address - Country:US
Practice Address - Phone:254-771-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant