Provider Demographics
NPI:1417787631
Name:POWELL, MALLORY (CPNP-PC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12661 W STATE HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:LIBERTY HILL
Mailing Address - State:TX
Mailing Address - Zip Code:78642-4729
Mailing Address - Country:US
Mailing Address - Phone:512-778-5111
Mailing Address - Fax:512-260-8103
Practice Address - Street 1:12661 W STATE HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:LIBERTY HILL
Practice Address - State:TX
Practice Address - Zip Code:78642-4729
Practice Address - Country:US
Practice Address - Phone:512-778-5111
Practice Address - Fax:512-260-8103
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1170341363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty