Provider Demographics
NPI:1134593957
Name:CARLETTI, MALLORY LAMBERT (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LAMBERT
Last Name:CARLETTI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:BROOKE
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:808 KELLER PKWY
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2405
Mailing Address - Country:US
Mailing Address - Phone:817-431-2573
Mailing Address - Fax:817-379-6881
Practice Address - Street 1:808 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2405
Practice Address - Country:US
Practice Address - Phone:817-431-2573
Practice Address - Fax:817-379-6881
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant