Provider Demographics
NPI:1831531755
Name:ANDERSON-DEBELL, MALLORY KATHLEEN (NPP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATHLEEN
Last Name:ANDERSON-DEBELL
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2452 ROUTE 9
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118
Mailing Address - Country:US
Mailing Address - Phone:518-292-5433
Mailing Address - Fax:
Practice Address - Street 1:2452 U.S ROUTE
Practice Address - Street 2:SUITE 206
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-5142
Practice Address - Country:US
Practice Address - Phone:518-292-5433
Practice Address - Fax:518-899-4930
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401616363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty