Provider Demographics
NPI:1942953419
Name:AVANT, MALLORY E (CRNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:E
Last Name:AVANT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 SUN TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-8643
Mailing Address - Country:US
Mailing Address - Phone:256-288-3333
Mailing Address - Fax:
Practice Address - Street 1:1800 BEVERLY AVE
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3255
Practice Address - Country:US
Practice Address - Phone:256-320-7475
Practice Address - Fax:256-325-1890
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN226068363LP0808X
AL3-000812363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health