Provider Demographics
NPI:1104166255
Name:ANDERSON, MALLORY BUNTON (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:BUNTON
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SUMMERPLACE DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3058
Mailing Address - Country:US
Mailing Address - Phone:803-794-4585
Mailing Address - Fax:803-796-8924
Practice Address - Street 1:131 SUMMERPLACE DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3058
Practice Address - Country:US
Practice Address - Phone:803-794-4585
Practice Address - Fax:803-796-8924
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner