Healthcare Provider Details

I. General information

NPI: 1013812189
Provider Name (Legal Business Name): MALLORY BITETZAKIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MALLORY MARIE MADRID

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 PRIMWOOD LN
LUTZ FL
33549-9347
US

IV. Provider business mailing address

1319 PRIMWOOD LN
LUTZ FL
33549-9347
US

V. Phone/Fax

Practice location:
  • Phone: 813-943-8458
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN9503271
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: