Provider Demographics
NPI:1073154787
Name:MARTIN, MALLORY B (NP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:B
Last Name:MARTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 N UNION BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3800
Mailing Address - Country:US
Mailing Address - Phone:719-434-8810
Mailing Address - Fax:519-805-2164
Practice Address - Street 1:2417 NW 174TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-7108
Practice Address - Country:US
Practice Address - Phone:405-255-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113578163W00000X
CO1257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse