Provider Demographics
NPI:1568404457
Name:MALLARD, SHELLEY H (APRN, BC, FNP)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:H
Last Name:MALLARD
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 JONES AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1510
Mailing Address - Country:US
Mailing Address - Phone:706-554-5147
Mailing Address - Fax:706-554-6111
Practice Address - Street 1:305 JONES AVE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-1510
Practice Address - Country:US
Practice Address - Phone:706-554-5147
Practice Address - Fax:706-554-6111
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR1129202363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS84515Medicare UPIN
GA50BBDRG01Medicare ID - Type Unspecified