Provider Demographics
NPI:1265856173
Name:FAHNESTOCK, MALLORY (DPT)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:FAHNESTOCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 W SAINT JOSEPH ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1504
Mailing Address - Country:US
Mailing Address - Phone:573-517-7900
Mailing Address - Fax:
Practice Address - Street 1:1506 W SAINT JOSEPH ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1504
Practice Address - Country:US
Practice Address - Phone:573-517-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014004288208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation