Provider Demographics
NPI:1205443165
Name:STOCKSTILL, MALLORY (FNP-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:STOCKSTILL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 EVELYN GANDY PKWY
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-3947
Mailing Address - Country:US
Mailing Address - Phone:601-584-4309
Mailing Address - Fax:601-584-4890
Practice Address - Street 1:1146 EVELYN GANDY PKWY
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3947
Practice Address - Country:US
Practice Address - Phone:601-584-4309
Practice Address - Fax:601-584-4890
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904135363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS904135OtherLICENSE VERIFICATION