Provider Demographics
NPI:1205526464
Name:WHITLOCK, MALLORY PAIGE (PAC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:PAIGE
Last Name:WHITLOCK
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINT HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-6768
Mailing Address - Country:US
Mailing Address - Phone:270-442-9461
Mailing Address - Fax:
Practice Address - Street 1:200 CLINT HILL BLVD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-6768
Practice Address - Country:US
Practice Address - Phone:270-442-9461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA3330363A00000X
KYTC041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant