Provider Demographics
NPI:1427815042
Name:MIZVITOWICZ, MALLORY LYNNE (CRNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNNE
Last Name:MIZVITOWICZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W DUPONT ST
Mailing Address - Street 2:
Mailing Address - City:RIDLEY PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19078-3207
Mailing Address - Country:US
Mailing Address - Phone:215-605-9015
Mailing Address - Fax:
Practice Address - Street 1:2002 SPROUL RD FL 3
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3510
Practice Address - Country:US
Practice Address - Phone:610-626-8085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028758363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health