Healthcare Provider Details

I. General information

NPI: 1427815042
Provider Name (Legal Business Name): MALLORY LYNNE MIZVITOWICZ CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 SPROUL RD FL 3
BROOMALL PA
19008-3510
US

IV. Provider business mailing address

207 W DUPONT ST
RIDLEY PARK PA
19078-3207
US

V. Phone/Fax

Practice location:
  • Phone: 610-626-8085
  • Fax:
Mailing address:
  • Phone: 215-605-9015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP028758
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: