Provider Demographics
NPI:1639843055
Name:MALLARD, CHATITY M (RN)
Entity Type:Individual
Prefix:
First Name:CHATITY
Middle Name:M
Last Name:MALLARD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 CHRISTOPHER CIR
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-8403
Mailing Address - Country:US
Mailing Address - Phone:478-501-3805
Mailing Address - Fax:
Practice Address - Street 1:176 CHRISTOPHER CIR
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-8403
Practice Address - Country:US
Practice Address - Phone:478-501-3805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home