Provider Demographics
NPI:1669666442
Name:WILBON, MALLORY J (APRN-FNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:J
Last Name:WILBON
Suffix:
Gender:F
Credentials:APRN-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2158 UNION AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4205
Mailing Address - Country:US
Mailing Address - Phone:901-728-5858
Mailing Address - Fax:901-507-0558
Practice Address - Street 1:2158 UNION AVE
Practice Address - Street 2:STE. 100
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4205
Practice Address - Country:US
Practice Address - Phone:901-728-5858
Practice Address - Fax:901-507-0558
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000010556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily