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General NPI Number Information
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NPI Number | 1801540646
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Entity Type | Individual
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Provider Name | MALLORY QUINN DE BOOM PA
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Gender | Female
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Dates
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Enumeration Date | 02/10/2022
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Last Update Date | 11/13/2024
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Provider Practice Location Address
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Address Line | 2004 EXETER RD
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City | GERMANTOWN
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State | TN
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Zip | 38138-3945
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Country | US
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Telephone | 901-664-2111
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Fax |
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Provider Business Mailing Address
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Address Line | 20770 US HIGHWAY 281 N # 108-439
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City | SAN ANTONIO
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State | TX
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Zip | 78258-7655
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4931
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License Number State | TN
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