Provider Demographics
NPI:1992384507
Name:MALLORY, KRISTIN LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LAUREN
Last Name:MALLORY
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 1:303 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2745
Mailing Address - Country:US
Mailing Address - Phone:706-882-8831
Mailing Address - Fax:706-812-4157
Practice Address - Street 1:303 SMITH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2745
Practice Address - Country:US
Practice Address - Phone:706-882-8831
Practice Address - Fax:706-812-4157
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily