Provider Demographics
NPI:1639311178
Name:O'BRIEN, MALLORY LYNN (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LYNN
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 BOWENS MILL RD STE H
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2252
Mailing Address - Country:US
Mailing Address - Phone:912-384-3838
Mailing Address - Fax:912-384-8847
Practice Address - Street 1:101 BOWENS MILL RD STE H
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2252
Practice Address - Country:US
Practice Address - Phone:912-384-3838
Practice Address - Fax:912-384-8847
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-30
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN233586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I500469Medicare PIN