Provider Demographics
NPI:1255640074
Name:BELLISSIMO, MALLORY K (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:K
Last Name:BELLISSIMO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:K
Other - Last Name:MEEHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:961 ADAIR AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3809
Mailing Address - Country:US
Mailing Address - Phone:717-497-6851
Mailing Address - Fax:
Practice Address - Street 1:3617 ROSWELL RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1111
Practice Address - Country:US
Practice Address - Phone:404-996-0196
Practice Address - Fax:404-467-2489
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10513363A00000X
WAPA60385985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA240855Medicare PIN