Healthcare Provider Details

I. General information

NPI: 1609239680
Provider Name (Legal Business Name): MALLORY ANNE MCINNES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N CLYDE MORRIS BLVD STE 200
DAYTONA BEACH FL
32114
US

IV. Provider business mailing address

303 N CLYDE MORRIS BLVD
DAYTONA BEACH FL
32114-2709
US

V. Phone/Fax

Practice location:
  • Phone: 386-425-4165
  • Fax: 386-425-4165
Mailing address:
  • Phone: 386-226-4590
  • Fax: 386-226-3371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME137213
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: