Provider Demographics
NPI:1306353685
Name:GANNAWAY, MALLERY GRAY (AA)
Entity type:Individual
Prefix:MRS
First Name:MALLERY
Middle Name:GRAY
Last Name:GANNAWAY
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 N MACARTHUR BLVD APT 304
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-3039
Mailing Address - Country:US
Mailing Address - Phone:405-406-7112
Mailing Address - Fax:
Practice Address - Street 1:12301 N MACARTHUR BLVD APT 304
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3039
Practice Address - Country:US
Practice Address - Phone:405-406-7112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK737390200000X
OK2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program