Healthcare Provider Details

I. General information

NPI: 1801671425
Provider Name (Legal Business Name): MALLORI MCBRYDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 S GLOSTER ST
TUPELO MS
38801-6343
US

IV. Provider business mailing address

808 VARSITY DR
TUPELO MS
38801-4613
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-4550
  • Fax: 662-377-4425
Mailing address:
  • Phone: 662-377-3204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906242
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: