Provider Demographics
NPI:1427458553
Name:MOWDY, MALLORY ELYSE (NP-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:ELYSE
Last Name:MOWDY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:ELYSE
Other - Last Name:MAGEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:724 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2460
Mailing Address - Country:US
Mailing Address - Phone:601-833-5255
Mailing Address - Fax:601-843-0252
Practice Address - Street 1:724 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2460
Practice Address - Country:US
Practice Address - Phone:601-833-5255
Practice Address - Fax:601-843-0252
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR877141363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02337065Medicaid
MS1427458553OtherBLUE CROSS BLUE SHIELD