Provider Demographics
NPI:1881258085
Name:GUAGENTI, MALLORY JADE (NP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:JADE
Last Name:GUAGENTI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 PARKER MDWS
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-4825
Mailing Address - Country:US
Mailing Address - Phone:270-589-7827
Mailing Address - Fax:
Practice Address - Street 1:3399 TATES CREEK RD STE 230
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-7404
Practice Address - Country:US
Practice Address - Phone:859-523-5893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013325207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine