Provider Demographics
NPI:1356854582
Name:GOETZ, MALLORY (AGACNP-BC)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
Last Name:GOETZ
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CAPTAIN JOHN BRICE WAY
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-6327
Mailing Address - Country:US
Mailing Address - Phone:214-477-8200
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:214-477-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR231169363LA2100X
TXAP135634363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care