MEDICARE: HALEY C MALLORY APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	3016595	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275277121
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY C MALLORY APRN

Provider Business Mailing Address
First Line	:	440 E HAPPY VALLEY ST
Second Line	:
City	:	CAVE CITY
State	:	KY
Zip	:	42127-8844
Country	:	US
Telephone Number	:	270-773-2111
Fax Number	:	270-773-2117

Provider Business Practice Location Address
First Line	:	440 E HAPPY VALLEY ST
Second Line	:
City	:	CAVE CITY
State	:	KY
Zip	:	42127-8844
Country	:	US
Telephone Number	:	270-773-2111
Fax Number	:	270-773-2117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2022
Last Update Date	:	03/02/2023

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