Provider Demographics
NPI:1588217491
Name:EBERLY, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:EBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 CORPORATE WOODS
Mailing Address - Street 2:STE 200C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1459
Mailing Address - Country:US
Mailing Address - Phone:585-784-7848
Mailing Address - Fax:
Practice Address - Street 1:2 RUBIN DR
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:NY
Practice Address - Zip Code:14544-9681
Practice Address - Country:US
Practice Address - Phone:585-554-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344949363AM0700X
NY628042-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical