Provider Demographics
NPI:1659703007
Name:POYNTER, MALLORY CLAIR (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:CLAIR
Last Name:POYNTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:CLAIR
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:160 N EAGLE CREEK DR STE 303
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2124
Practice Address - Country:US
Practice Address - Phone:859-899-9240
Practice Address - Fax:859-899-9250
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2969363AS0400X
TXPA09558363AS0400X
KYPA3172363AS0400X
KYTC345363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2969OtherPA LICENSE
TXPA09558OtherTEXAS PHYSICIAN ASSISTANT LICENSE
KY7100869150Medicaid