Healthcare Provider Details

I. General information

NPI: 1629587530
Provider Name (Legal Business Name): MARY MALLORY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6160 KEMPSVILLE CIR STE 325A
NORFOLK VA
23502-3933
US

IV. Provider business mailing address

900 MOUNTAIN LAUREL TRL
VIRGINIA BEACH VA
23454-3552
US

V. Phone/Fax

Practice location:
  • Phone: 757-354-2885
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024174999
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024174999
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: