Healthcare Provider Details

I. General information

NPI: 1669626156
Provider Name (Legal Business Name): DANA ELIZABETH MALLORY MS, CCC-SLP, RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7120 BROOKVIEW LN
SHERRILLS FORD NC
28673-9514
US

IV. Provider business mailing address

7120 BROOKVIEW LN
SHERRILLS FORD NC
28673-9514
US

V. Phone/Fax

Practice location:
  • Phone: 845-514-7793
  • Fax:
Mailing address:
  • Phone: 845-514-7793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number607662-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number376253
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number013221-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number30003595
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: