Provider Demographics
NPI:1639800634
Name:FICKLING SULLIVAN, MALLORY PAIGE (APRN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:PAIGE
Last Name:FICKLING SULLIVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12234 PANAMA CITY BEACH PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2726
Mailing Address - Country:US
Mailing Address - Phone:850-233-2323
Mailing Address - Fax:850-233-1055
Practice Address - Street 1:12234 PANAMA CITY BEACH PKWY STE C
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-2726
Practice Address - Country:US
Practice Address - Phone:850-233-2323
Practice Address - Fax:850-233-1055
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020277363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner