Provider Demographics
NPI:1760008429
Name:GUESS, MALLORY ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:GUESS
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:
Practice Address - Street 1:3999 DUTCHMANS LN STE 6F
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4724
Practice Address - Country:US
Practice Address - Phone:502-394-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant