Provider Demographics
NPI:1134443658
Name:SCALLORN, MARY (ARNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:SCALLORN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2936 DANIELS ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-2912
Mailing Address - Country:US
Mailing Address - Phone:850-526-7123
Mailing Address - Fax:
Practice Address - Street 1:2928 DANIELS ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-2912
Practice Address - Country:US
Practice Address - Phone:850-526-3555
Practice Address - Fax:850-526-3570
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2184442363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001961500Medicaid