Provider Demographics
NPI:1720508120
Name:LYNCH, MALLORY WATHEN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:WATHEN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:MALLORY
Other - Middle Name:ANN
Other - Last Name:WATHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:815 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:BRANDENBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40108-1415
Mailing Address - Country:US
Mailing Address - Phone:270-422-4111
Mailing Address - Fax:270-422-3629
Practice Address - Street 1:815 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1415
Practice Address - Country:US
Practice Address - Phone:270-422-4111
Practice Address - Fax:270-422-3629
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011343363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily