Provider Demographics
NPI:1104589183
Name:HERNANDEZ, MALLORI WEAVER (NP)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:WEAVER
Last Name:HERNANDEZ
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 1:10500 LAKELINE MALL DR APT 4202
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-0078
Mailing Address - Country:US
Mailing Address - Phone:512-214-2700
Mailing Address - Fax:
Practice Address - Street 1:11673 JOLLYVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4211
Practice Address - Country:US
Practice Address - Phone:512-342-7979
Practice Address - Fax:512-637-2596
Is Sole Proprietor?:No
Enumeration Date:2021-10-18
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1057095363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health