Provider Demographics
NPI:1710612718
Name:MOODY, MALLORY BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:MOODY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:55 HUMPHREYS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2374
Mailing Address - Country:US
Mailing Address - Phone:901-747-0040
Mailing Address - Fax:
Practice Address - Street 1:55 HUMPHREYS CENTER DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2374
Practice Address - Country:US
Practice Address - Phone:901-747-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant