Provider Demographics
NPI:1790347672
Name:ANDRZEJAK, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ANDRZEJAK
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 1:55 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1205
Mailing Address - Country:US
Mailing Address - Phone:716-831-2700
Mailing Address - Fax:
Practice Address - Street 1:55 DODGE RD
Practice Address - Street 2:
Practice Address - City:GETZVILLE
Practice Address - State:NY
Practice Address - Zip Code:14068-1205
Practice Address - Country:US
Practice Address - Phone:716-831-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345270363L00000X
NYF345270-01363LF0000X
NY672613163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse