Provider Demographics
NPI:1619549995
Name:VANNOY, MALLERY LYNN
Entity Type:Individual
Prefix:
First Name:MALLERY
Middle Name:LYNN
Last Name:VANNOY
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 1:1926 AVON DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-3428
Mailing Address - Country:US
Mailing Address - Phone:814-462-8479
Mailing Address - Fax:
Practice Address - Street 1:1611 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-2109
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)