Provider Demographics
NPI:1780657874
Name:MALLORY, DEBORAH L (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:MALLORY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 OLD ROCKY RIDGE ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35216-7251
Mailing Address - Country:US
Mailing Address - Phone:205-989-1080
Mailing Address - Fax:205-989-1087
Practice Address - Street 1:470 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-226-4048
Practice Address - Fax:334-323-5675
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-025129367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-35357OtherBCBS
AL000035357Medicaid
AL430044804OtherMEDICARE RR