Provider Demographics
NPI:1528797156
Name:STOLLY, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:STOLLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2062 E CAMERON WAY APT 2067
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-7069
Mailing Address - Country:US
Mailing Address - Phone:937-597-3557
Mailing Address - Fax:
Practice Address - Street 1:3160 N ARIZONA AVE STE 106
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-7122
Practice Address - Country:US
Practice Address - Phone:480-699-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology