Provider Demographics
NPI:1285058958
Name:MALLORY, KARISSA MAE (PTA)
Entity type:Individual
Prefix:MRS
First Name:KARISSA
Middle Name:MAE
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 RUBY VISTA DR
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-1615
Mailing Address - Country:US
Mailing Address - Phone:775-753-5500
Mailing Address - Fax:
Practice Address - Street 1:2850 RUBY VISTA DR
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-1615
Practice Address - Country:US
Practice Address - Phone:775-753-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-0667225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant