Provider Demographics
NPI:1124754320
Name:GOLDMAN, MALLORY A (AGACNP-BC, DNP)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:A
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:AGACNP-BC, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FORD PL STE 3A
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3450
Mailing Address - Country:US
Mailing Address - Phone:313-874-4806
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704327448363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care