Provider Demographics
NPI:1598223216
Name:MALLORY, LISA R (AGNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:MALLORY
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:ADKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:506 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1204
Practice Address - Country:US
Practice Address - Phone:304-766-8558
Practice Address - Fax:304-766-8561
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN741400AGPCNP-BC363LG0600X
WVAPRN74140-AGPCNP-BC363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810024049OtherGROUP MEDICAID
WVB441OtherMEDICARE GROUP