Provider Demographics
NPI:1760187165
Name:O'MALLEY, NICOLE SANFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:SANFORD
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:NICOLE
Other - Last Name:SANFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 N DUNLAP ST # 20
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2800
Mailing Address - Country:US
Mailing Address - Phone:901-287-5319
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE STE 447
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-287-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program