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General NPI Number Information
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NPI Number | 1861913592
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Entity Type | Individual
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Provider Name | MALLORY C WHITLEY MD
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Gender | Female
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Dates
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Enumeration Date | 07/03/2017
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Last Update Date | 07/16/2025
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Provider Practice Location Address
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Address Line | 4844 DEER LAKE DR W STE 1
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City | JACKSONVILLE
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State | FL
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Zip | 32246-4506
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Country | US
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Telephone | 904-738-8690
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Fax | 904-390-7426
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Provider Business Mailing Address
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Address Line | 4844 DEER LAKE DR W
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City | JACKSONVILLE
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State | FL
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Zip | 32246-4406
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Country | US
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Telephone | 904-738-8690
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Fax | 904-390-7426
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME137670
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License Number State | FL
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