MEDICARE: MRS. MALLORY STEWART LOTT ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	9362485	FL
2	363LA2200X	Adult Health Nurse Practitioner	9362485	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9362485	OTHER	FL	ARNP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609397934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MALLORY STEWART LOTT ARNP

Provider Business Mailing Address
First Line	:	10718 COUNTRYWAY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1733
Country	:	US
Telephone Number	:	813-844-4800
Fax Number	:

Provider Business Practice Location Address
First Line	:	10718 COUNTRYWAY BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33626-1733
Country	:	US
Telephone Number	:	813-844-4800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2017
Last Update Date	:	06/09/2021

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