Provider Demographics
NPI:1396224754
Name:DIXON, MALLORY MCGOFF (DNP FNP-C)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:MCGOFF
Last Name:DIXON
Suffix:
Gender:F
Credentials:DNP FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 WOLF PARK DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1741
Practice Address - Country:US
Practice Address - Phone:901-755-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ041326Medicaid