Provider Demographics
NPI:1891209086
Name:MELBY, MALLORY J (PA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:J
Last Name:MELBY
Suffix:
Gender:F
Credentials:PA
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 21850
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71903-1850
Mailing Address - Country:US
Mailing Address - Phone:501-321-2663
Mailing Address - Fax:
Practice Address - Street 1:1662 HIGDON FERRY RD STE 300
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6982
Practice Address - Country:US
Practice Address - Phone:501-321-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant