MEDICARE: CAROL MALLORY NURSE PRACTITIONER

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	363L00000X	Nurse Practitioner	APN000968	NV

General Provider Information

NPI Number	:	1821243486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL MALLORY NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1231 COUNTRY CLUB DR
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89703-8372
Country	:	US
Telephone Number	:	775-884-3990
Fax Number	:	775-884-2202

Provider Business Practice Location Address
First Line	:	1231 COUNTRY CLUB DR
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89703-8372
Country	:	US
Telephone Number	:	775-884-3990
Fax Number	:	775-884-2202

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

Provider Enumeration Date	:	11/24/2008
Last Update Date	:	11/24/2008

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