Provider Demographics
NPI:1609334630
Name:SMITH, MALLORY LYNNE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 WASHINGTON AVE APT 361
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-6325
Mailing Address - Country:US
Mailing Address - Phone:385-319-5445
Mailing Address - Fax:
Practice Address - Street 1:17189 INTERSTATE 45 S STE 675
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-3320
Practice Address - Country:US
Practice Address - Phone:936-270-3900
Practice Address - Fax:936-271-1584
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014580363LC0200X
TXAP140939363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine