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General NPI Number Information
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NPI Number | 1629587530
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Entity Type | Individual
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Provider Name | MARY MALLORY NP
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Gender | Female
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 07/22/2019
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Provider Practice Location Address
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Address Line | 7202 POPLAR ST STE E
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City | ANNANDALE
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State | VA
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Zip | 22003-3025
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Country | US
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Telephone | 571-830-6195
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Fax |
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Provider Business Mailing Address
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Address Line | 900 MOUNTAIN LAUREL TRL
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City | VIRGINIA BEACH
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State | VA
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Zip | 23454-3552
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Country | US
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Telephone |
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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 | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 0024174999
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 0024174999
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License Number State | VA
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