Healthcare Provider Details

I. General information

NPI: 1376422139
Provider Name (Legal Business Name): MALLORY JENE GRANI APRN, CNP, PMHNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MALLORY JENE HALLING

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 W LAKE ST
CHISHOLM MN
55719-1817
US

IV. Provider business mailing address

12 W LAKE ST
CHISHOLM MN
55719-1817
US

V. Phone/Fax

Practice location:
  • Phone: 218-254-0101
  • Fax:
Mailing address:
  • Phone: 218-254-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200991
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: