Provider Demographics
NPI:1851617526
Name:HENRY, MALLORY LANE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LANE
Last Name:HENRY
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-362-0338
Practice Address - Street 1:1600 S BRENTWOOD BLVD
Practice Address - Street 2:DIV NEUROLOGY GENERAL, STE 600
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-1320
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-362-0338
Is Sole Proprietor?:No
Enumeration Date:2010-04-20
Last Update Date:2024-04-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2013012266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220047038Medicaid
MO1851617526Medicaid