Provider Demographics
NPI:1538538251
Name:MCCOMB, MALLORIE (NP)
Entity type:Individual
Prefix:
First Name:MALLORIE
Middle Name:
Last Name:MCCOMB
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:
Other - Last Name:KETTLEUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2325 GARFIELD RD N
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-252-2767
Mailing Address - Fax:
Practice Address - Street 1:2325 GARFIELD RD N
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-252-2767
Practice Address - Fax:231-252-3751
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704279019363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner