Provider Demographics
NPI:1851152789
Name:MALLORY, AHONESTI RACHELLE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:AHONESTI
Middle Name:RACHELLE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:LPN
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 32
Mailing Address - Street 2:
Mailing Address - City:STRANG
Mailing Address - State:OK
Mailing Address - Zip Code:74367-0032
Mailing Address - Country:US
Mailing Address - Phone:918-934-4863
Mailing Address - Fax:
Practice Address - Street 1:594 EAGLE POINT RD
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:OK
Practice Address - Zip Code:74350-0032
Practice Address - Country:US
Practice Address - Phone:918-934-4863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0066111164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty