Provider Demographics
NPI:1124117296
Name:MALLORY, TERRY K (ARNP)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:K
Last Name:MALLORY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 6TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1866
Mailing Address - Country:US
Mailing Address - Phone:360-337-5235
Mailing Address - Fax:360-337-5259
Practice Address - Street 1:345 6TH ST STE 300
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1866
Practice Address - Country:US
Practice Address - Phone:360-337-5235
Practice Address - Fax:360-337-5259
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30000361363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9616400Medicaid
WA137845OtherL & I
MA8337OtherREGENCE