Healthcare Provider Details

I. General information

NPI: 1639417215
Provider Name (Legal Business Name): MALLORY MATHIS CARROLL PNP, FNP, MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 7TH AVE S # CPPNM20
BIRMINGHAM AL
35233-1711
US

IV. Provider business mailing address

1600 7TH AVE S # CPPNM20
BIRMINGHAM AL
35233-1711
US

V. Phone/Fax

Practice location:
  • Phone: 205-638-9072
  • Fax: 205-638-2833
Mailing address:
  • Phone: 205-638-9072
  • Fax: 205-638-2833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-185381
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: