Provider Demographics
NPI:1740864180
Name:MOORE, MALLORY BUTLER (CRNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:BUTLER
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7832 HORSESHOE TRL SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-3218
Mailing Address - Country:US
Mailing Address - Phone:256-457-8547
Mailing Address - Fax:
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4470
Practice Address - Country:US
Practice Address - Phone:256-265-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-149936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner