Provider Demographics
NPI:1215346408
Name:GERGELY, MALLORY NICOLE
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:NICOLE
Last Name:GERGELY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MALLORY
Other - Middle Name:NICOLE
Other - Last Name:GALLUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 JEFFERSON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2538
Mailing Address - Country:US
Mailing Address - Phone:724-527-8060
Mailing Address - Fax:724-522-4002
Practice Address - Street 1:1010 LIGONIER ST
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1846
Practice Address - Country:US
Practice Address - Phone:724-589-8581
Practice Address - Fax:724-539-2739
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA404674Medicare PIN