Provider Demographics
NPI:1720307978
Name:MALLOY, AMITY JILL (MSN, APN, NP)
Entity Type:Individual
Prefix:MRS
First Name:AMITY
Middle Name:JILL
Last Name:MALLOY
Suffix:
Gender:F
Credentials:MSN, APN, NP
Other - Prefix:
Other - First Name:AMITY
Other - Middle Name:JILL
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6216 AIRPARK DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2988
Mailing Address - Country:US
Mailing Address - Phone:423-899-0024
Mailing Address - Fax:423-899-5688
Practice Address - Street 1:6216 AIRPARK DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2988
Practice Address - Country:US
Practice Address - Phone:423-899-0024
Practice Address - Fax:423-899-5688
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14962363LP0808X, 363LP0808X
VA0024168722363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518283Medicaid
103I503557Medicare UPIN