Provider Demographics
NPI:1710699814
Name:MANKIN, MALLORY (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MANKIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6590 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-7405
Mailing Address - Country:US
Mailing Address - Phone:317-373-6392
Mailing Address - Fax:
Practice Address - Street 1:4903 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-5938
Practice Address - Country:US
Practice Address - Phone:317-352-5582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant