Healthcare Provider Details

I. General information

NPI: 1316468762
Provider Name (Legal Business Name): MALLORY CUSHNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/21/2022
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

973 MICA DRIVE SUITE 201
CARSON CITY NV
89705-7258
US

IV. Provider business mailing address

973 MICA DR STE 201
CARSON CITY NV
89705-7258
US

V. Phone/Fax

Practice location:
  • Phone: 775-783-6109
  • Fax:
Mailing address:
  • Phone: 775-783-6109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTAPRN701656
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN002663
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN236296
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: