Provider Demographics
NPI:1861854572
Name:SANDRIDGE, MALLORY (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SANDRIDGE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 HARRIS COURT, BUILDING T
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5750
Mailing Address - Country:US
Mailing Address - Phone:831-375-4105
Mailing Address - Fax:831-372-5722
Practice Address - Street 1:5 HARRIS COURT, BUILDING T
Practice Address - Street 2:SUITE 201
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5750
Practice Address - Country:US
Practice Address - Phone:831-375-4105
Practice Address - Fax:831-372-5722
Is Sole Proprietor?:No
Enumeration Date:2016-03-22
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173408363L00000X, 363LF0000X
CA95010564363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN