Provider Demographics
NPI:1700343423
Name:RUTLAND, MALLORY TUCKER
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:TUCKER
Last Name:RUTLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ELAINE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:506 LEE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5448
Mailing Address - Country:US
Mailing Address - Phone:912-856-3792
Mailing Address - Fax:
Practice Address - Street 1:506 LEE BLVD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5448
Practice Address - Country:US
Practice Address - Phone:912-856-3792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN235650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily