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General NPI Number Information
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NPI Number | 1922976422
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Entity Type | Individual
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Provider Name | ETHAN DAVIS MALLORY FNP-C
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Gender | Male
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Dates
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Enumeration Date | 10/27/2025
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 3201 MCCLELLAND BLVD SUITE B
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City | JOPLIN
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State | MO
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Zip | 64804
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Country | US
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Telephone | 417-347-6625
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Fax |
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Provider Business Mailing Address
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Address Line | 3708 CHELSEA
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City | WEBB CITY
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State | MO
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Zip | 64870-9572
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Country | US
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Telephone | 417-483-2014
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 2025036708
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License Number State | MO
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