Healthcare Provider Details

I. General information

NPI: 1780151001
Provider Name (Legal Business Name): MALLORY JACOB WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAIN ST APT 205
PEMBROKE NH
03275-1241
US

IV. Provider business mailing address

111 NEW HAMPSHIRE AVE STE 2
PORTSMOUTH NH
03801-2864
US

V. Phone/Fax

Practice location:
  • Phone: 802-274-8902
  • Fax:
Mailing address:
  • Phone: 603-319-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1466
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: