Provider Demographics
NPI:1831500933
Name:CRANMER, MALLORY
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:CRANMER
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 1:9314 OLD KEENE MILL RD STE A
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4284
Mailing Address - Country:US
Mailing Address - Phone:703-569-3131
Mailing Address - Fax:
Practice Address - Street 1:9314 OLD KEENE MILL RD STE A
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-4284
Practice Address - Country:US
Practice Address - Phone:703-569-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-12
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT2840152W00000X
VA0618002858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist