MEDICARE: DANA ELIZABETH MALLORY MS, CCC-SLP, RN, BSN

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	163W00000X	Registered Nurse	607662-1	NY
2	163W00000X	Registered Nurse	376253	NC
3	235Z00000X	Speech-Language Pathologist	013221-1	NY
4	235Z00000X	Speech-Language Pathologist	30003595	NC

General Provider Information

NPI Number	:	1669626156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA ELIZABETH MALLORY MS, CCC-SLP, RN, BSN

Provider Business Mailing Address
First Line	:	7120 BROOKVIEW LN
Second Line	:
City	:	SHERRILLS FORD
State	:	NC
Zip	:	28673-9514
Country	:	US
Telephone Number	:	845-514-7793
Fax Number	:

Provider Business Practice Location Address
First Line	:	7120 BROOKVIEW LN
Second Line	:
City	:	SHERRILLS FORD
State	:	NC
Zip	:	28673-9514
Country	:	US
Telephone Number	:	845-514-7793
Fax Number	:

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

Provider Enumeration Date	:	11/10/2008
Last Update Date	:	06/15/2025

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