Healthcare Provider Details

I. General information

NPI: 1942731815
Provider Name (Legal Business Name): MALLORY TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CADILLAC DR STE 200
SACRAMENTO CA
95825-8337
US

IV. Provider business mailing address

1860 HOWE AVE STE 440
SACRAMENTO CA
95825-1098
US

V. Phone/Fax

Practice location:
  • Phone: 916-454-2345
  • Fax:
Mailing address:
  • Phone: 916-569-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA160930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: