Provider Demographics
NPI:1740848985
Name:DES CHAMPS, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DES CHAMPS
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 1:1150 DOUGLAS PIKE
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02917-1291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH AVE STE A20
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3957
Practice Address - Country:US
Practice Address - Phone:718-491-5800
Practice Address - Fax:718-748-2151
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical