Provider Demographics
NPI:1619636941
Name:MUNROE, MALLORY (CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MUNROE
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:674 W 18TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-5018
Mailing Address - Country:US
Mailing Address - Phone:657-600-1174
Mailing Address - Fax:
Practice Address - Street 1:16105 SAND CANYON AVE STE 200
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3779
Practice Address - Country:US
Practice Address - Phone:949-829-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019413363LW0102X
CA236234367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health