Healthcare Provider Details

I. General information

NPI: 1609797679
Provider Name (Legal Business Name): MALLORY MAXWELL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 W 21ST ST
CLOVIS NM
88101-4149
US

IV. Provider business mailing address

912 W 21ST ST
CLOVIS NM
88101-4149
US

V. Phone/Fax

Practice location:
  • Phone: 575-935-9000
  • Fax: 575-935-1002
Mailing address:
  • Phone: 575-935-9000
  • Fax: 575-935-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number90737
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: