Healthcare Provider Details

I. General information

NPI: 1609334630
Provider Name (Legal Business Name): MALLORY LYNNE SMITH AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2019
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 KRESGE WAY STE 42
LOUISVILLE KY
40207-4681
US

IV. Provider business mailing address

1901 CAMPUS PL
LOUISVILLE KY
40299-2308
US

V. Phone/Fax

Practice location:
  • Phone: 502-899-3858
  • Fax: 502-899-3878
Mailing address:
  • Phone: 502-253-4924
  • Fax: 502-489-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4018626
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP140939
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number95014580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: