Provider Demographics
NPI:1578972501
Name:MOORE, MALLORY (LPN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 REFUGEE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-5355
Mailing Address - Country:US
Mailing Address - Phone:614-632-3487
Mailing Address - Fax:614-340-4671
Practice Address - Street 1:5252 REFUGEE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-5355
Practice Address - Country:US
Practice Address - Phone:614-636-2811
Practice Address - Fax:614-340-4671
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH155601164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse