Provider Demographics
NPI:1578734844
Name:MALLORY, NICOLE M (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1431 WASHINGTON BLVD
Mailing Address - Street 2:APT 1716
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28800 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-4272
Practice Address - Country:US
Practice Address - Phone:586-573-6400
Practice Address - Fax:586-576-1918
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical