Healthcare Provider Details

I. General information

NPI: 1629996152
Provider Name (Legal Business Name): KIEARA MALLORY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7597 SADDLEBROOK AVE
PACE FL
32571-9854
US

IV. Provider business mailing address

7597 SADDLEBROOK AVE
PACE FL
32571-9854
US

V. Phone/Fax

Practice location:
  • Phone: 931-220-1607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number9648548
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: