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General NPI Number Information
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NPI Number | 1588273122
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Entity Type | Individual
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Provider Name | MALLORY MARY NELSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/29/2020
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Last Update Date | 01/29/2025
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Provider Practice Location Address
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Address Line | 2 SHIRCLIFF WAY BLDG SUITE635
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City | JACKSONVILLE
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State | FL
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Zip | 32204-4753
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Country | US
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Telephone | 904-922-4009
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Fax |
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Provider Business Mailing Address
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Address Line | 75436 BANYAN WAY
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City | YULEE
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State | FL
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Zip | 32097-0231
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Country | US
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Telephone | 404-797-9949
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 9862
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License Number State | GA
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