Provider Demographics
NPI:1598286072
Name:MARTIN, MARY MALLORY (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MALLORY
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 HIGHWAY 78 EAST
Mailing Address - Street 2:SUITE 412
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-4718
Mailing Address - Country:US
Mailing Address - Phone:205-384-3013
Mailing Address - Fax:205-384-3078
Practice Address - Street 1:3400 HIGHWAY 78 E STE 412
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8952
Practice Address - Country:US
Practice Address - Phone:205-384-3013
Practice Address - Fax:205-384-3078
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-137813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily