Provider Demographics
NPI:1780151001
Name:WALSH, MALLORY JACOB
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JACOB
Last Name:WALSH
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 1:111 NEW HAMPSHIRE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2864
Mailing Address - Country:US
Mailing Address - Phone:603-319-4490
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST APT 205
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NH
Practice Address - Zip Code:03275-1241
Practice Address - Country:US
Practice Address - Phone:802-274-8902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X, 390200000X
NH1466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program