Provider Demographics
NPI:1528702677
Name:LEDBETTER, MALLORY KATE (APRN)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATE
Last Name:LEDBETTER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MALLLRY
Other - Middle Name:KATE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 VILLA DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:38570-2905
Mailing Address - Country:US
Mailing Address - Phone:931-644-6182
Mailing Address - Fax:
Practice Address - Street 1:1101 NEAL ST
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0901
Practice Address - Country:US
Practice Address - Phone:931-507-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily