Provider Demographics
NPI:1689116055
Name:MALLORY, AMANDA (NP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 DAWSONS PARK WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-1906
Mailing Address - Country:US
Mailing Address - Phone:038-240-9995
Mailing Address - Fax:
Practice Address - Street 1:1847 S LAKE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-7759
Practice Address - Country:US
Practice Address - Phone:803-356-8998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily