Provider Demographics
NPI:1962028910
Name:BANE, MALLORYE ANN (RN)
Entity Type:Individual
Prefix:
First Name:MALLORYE
Middle Name:ANN
Last Name:BANE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3119
Mailing Address - Country:US
Mailing Address - Phone:970-565-3056
Mailing Address - Fax:
Practice Address - Street 1:106 W NORTH ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3119
Practice Address - Country:US
Practice Address - Phone:970-565-3056
Practice Address - Fax:970-565-0647
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.16658152083P0901X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine