Provider Demographics
NPI:1093248379
Name:DACUS, MALLORY ROBERTS (MD)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:ROBERTS
Last Name:DACUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2200 CHILDRENS WAY FL 9
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37232-0005
Mailing Address - Country:US
Mailing Address - Phone:615-322-6875
Mailing Address - Fax:
Practice Address - Street 1:2200 CHILDRENS WAY FL 9
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0005
Practice Address - Country:US
Practice Address - Phone:615-343-2452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program