MEDICARE: AMANDA MALLORY NP

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	20586	SC

General Provider Information

NPI Number	:	1689116055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA MALLORY NP

Provider Business Mailing Address
First Line	:	703 DAWSONS PARK WAY
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-1906
Country	:	US
Telephone Number	:	38-240-9995
Fax Number	:

Provider Business Practice Location Address
First Line	:	1847 S LAKE DR
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29073-7759
Country	:	US
Telephone Number	:	803-356-8998
Fax Number	:

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

Provider Enumeration Date	:	11/16/2016
Last Update Date	:	02/01/2021

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