Provider Demographics
NPI:1740987478
Name:NOLAN, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:NOLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 SPALDING DR UNIT 924649
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2503
Mailing Address - Country:US
Mailing Address - Phone:404-805-8131
Mailing Address - Fax:
Practice Address - Street 1:99 KROG ST NE STE C110
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-2677
Practice Address - Country:US
Practice Address - Phone:404-885-8542
Practice Address - Fax:404-393-9936
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN306431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily