Provider Demographics
NPI:1659992899
Name:GRAY, MALLORY MARYRUTH (CPNP-PC)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:MARYRUTH
Last Name:GRAY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2106
Mailing Address - Country:US
Mailing Address - Phone:770-312-5566
Mailing Address - Fax:
Practice Address - Street 1:350 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2106
Practice Address - Country:US
Practice Address - Phone:404-508-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN262243363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics