Provider Demographics
NPI:1265177984
Name:MALLORY, CAMILLE HAYES (NP)
Entity type:Individual
Prefix:MRS
First Name:CAMILLE
Middle Name:HAYES
Last Name:MALLORY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6005 PARK AVE STE 500B
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5215
Mailing Address - Country:US
Mailing Address - Phone:901-683-6925
Mailing Address - Fax:844-630-9771
Practice Address - Street 1:6005 PARK AVE STE 500B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5215
Practice Address - Country:US
Practice Address - Phone:901-683-6925
Practice Address - Fax:844-630-9771
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-28
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28586363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily