Provider Demographics
NPI:1588273122
Name:NELSON, MALLORY MARY (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARY
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75436 BANYAN WAY
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-0231
Mailing Address - Country:US
Mailing Address - Phone:404-797-9949
Mailing Address - Fax:
Practice Address - Street 1:2 SHIRCLIFF WAY BLDG SUITE635
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4753
Practice Address - Country:US
Practice Address - Phone:904-922-4009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9862363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty