Provider Demographics
NPI:1912567447
Name:WASHINGTON, MALLORY (APRN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WASHINGTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 SHAKERAG HILL STE 201
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4047
Mailing Address - Country:US
Mailing Address - Phone:770-486-7111
Mailing Address - Fax:770-486-7131
Practice Address - Street 1:101 YORKTOWN DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1578
Practice Address - Country:US
Practice Address - Phone:770-460-4285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA232916363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics