Provider Demographics
NPI:1669127239
Name:GREEN, MALLORY ANN
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANN
Last Name:GREEN
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 1:222 ALEXANDER ST STE 5000
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-4064
Mailing Address - Country:US
Mailing Address - Phone:585-922-8003
Mailing Address - Fax:
Practice Address - Street 1:222 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-4039
Practice Address - Country:US
Practice Address - Phone:585-922-8003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-13
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical