Healthcare Provider Details

I. General information

NPI: 1922926146
Provider Name (Legal Business Name): MALLORY SOTELO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3334 CAPITAL MEDICAL BLVD STE 400
TALLAHASSEE FL
32308-4470
US

IV. Provider business mailing address

853 MILLBRIDGE DR
PANAMA CITY BEACH FL
32413-2291
US

V. Phone/Fax

Practice location:
  • Phone: 813-987-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11048935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: