Provider Demographics
NPI:1215607635
Name:PRICE, MALLORY (AGACNP-BC, FNP-BC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:PRICE
Suffix:
Gender:F
Credentials:AGACNP-BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 ETTA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT GABRIEL
Mailing Address - State:LA
Mailing Address - Zip Code:70776-5624
Mailing Address - Country:US
Mailing Address - Phone:601-807-3760
Mailing Address - Fax:
Practice Address - Street 1:8585 PICARDY AVE STE 313
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3749
Practice Address - Country:US
Practice Address - Phone:225-381-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221476363LF0000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily