Provider Demographics
NPI:1093510968
Name:RUST, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:RUST
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 AMBERCREST CT
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-6604
Mailing Address - Country:US
Mailing Address - Phone:678-897-3883
Mailing Address - Fax:
Practice Address - Street 1:6060 AMBERCREST CT
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-6604
Practice Address - Country:US
Practice Address - Phone:678-897-3883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-15
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer