Provider Demographics
NPI:1497469282
Name:LEBLANC, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LEBLANC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-2018
Mailing Address - Country:US
Mailing Address - Phone:954-262-1250
Mailing Address - Fax:
Practice Address - Street 1:6931 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2902
Practice Address - Country:US
Practice Address - Phone:954-321-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL9119379363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program