Provider Demographics
NPI:1811307671
Name:CREEKMORE, MALLORY E (MED)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:E
Last Name:CREEKMORE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9308 NORTHLAKE PKWY
Mailing Address - Street 2:112
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-5734
Mailing Address - Country:US
Mailing Address - Phone:407-701-1126
Mailing Address - Fax:
Practice Address - Street 1:9308 NORTHLAKE PKWY
Practice Address - Street 2:112
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5734
Practice Address - Country:US
Practice Address - Phone:407-701-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist