Provider Demographics
NPI:1679547442
Name:MALLORY, CLAUDETTE M (APRN)
Entity Type:Individual
Prefix:MRS
First Name:CLAUDETTE
Middle Name:M
Last Name:MALLORY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:92 W LOWDER ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2676
Mailing Address - Country:US
Mailing Address - Phone:904-259-0092
Mailing Address - Fax:904-259-0094
Practice Address - Street 1:92 W LOWDER ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2676
Practice Address - Country:US
Practice Address - Phone:904-259-0092
Practice Address - Fax:904-259-0094
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN3174462363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL770015600Medicaid
P32548Medicare UPIN
FL770015600Medicaid