Provider Demographics
NPI:1780420208
Name:RICKETTS, MALLORY DANIELLE (CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:DANIELLE
Last Name:RICKETTS
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3827 JESSICA LN
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-5307
Mailing Address - Country:US
Mailing Address - Phone:205-451-6641
Mailing Address - Fax:
Practice Address - Street 1:320 PELHAM AVE SW STE 301
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5051
Practice Address - Country:US
Practice Address - Phone:256-759-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALCNM09441207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology