Healthcare Provider Details

I. General information

NPI: 1700710795
Provider Name (Legal Business Name): MALLORY HASLAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

52 UNDERWOOD ST
ORLANDO FL
32806-1110
US

V. Phone/Fax

Practice location:
  • Phone: 407-416-6825
  • Fax:
Mailing address:
  • Phone: 407-416-6825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11041528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: