Provider Demographics
NPI:1659707057
Name:FORT, MALLORY (PNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NASHVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-1004
Mailing Address - Country:US
Mailing Address - Phone:931-388-8965
Mailing Address - Fax:931-388-0815
Practice Address - Street 1:1600 NASHVILLE HWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-1004
Practice Address - Country:US
Practice Address - Phone:931-388-8965
Practice Address - Fax:931-388-0815
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN17959363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics