Provider Demographics
NPI:1639169717
Name:MALLORY, DONNA MARIE (AUD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:MARIE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 ORANGE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CULPEPER
Mailing Address - State:VA
Mailing Address - Zip Code:22701-4170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2002 ORANGE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CULPEPER
Practice Address - State:VA
Practice Address - Zip Code:22701-4170
Practice Address - Country:US
Practice Address - Phone:540-829-9005
Practice Address - Fax:540-829-9056
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201000649231H00000X
VA2101001248231HA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010332371Medicaid
VA010332371Medicaid