Provider Demographics
NPI:1184116725
Name:METRAW, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:METRAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HICKORY WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-4917
Mailing Address - Country:US
Mailing Address - Phone:770-330-3492
Mailing Address - Fax:
Practice Address - Street 1:78 OPAL ST
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2848
Practice Address - Country:US
Practice Address - Phone:770-382-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002680390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program