Provider Demographics
NPI:1154992550
Name:MONTES, MALLORY MAYERS (DNP, FNP-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MAYERS
Last Name:MONTES
Suffix:
Gender:F
Credentials:DNP, FNP-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:CAITLIN
Other - Last Name:MAYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-0780
Mailing Address - Country:US
Mailing Address - Phone:706-595-1090
Mailing Address - Fax:
Practice Address - Street 1:315 FLUKER ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2108
Practice Address - Country:US
Practice Address - Phone:706-595-1090
Practice Address - Fax:706-595-6010
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAF06211739363LF0000X
GARN216727363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003255026FMedicaid