Provider Demographics
NPI:1588340046
Name:DEVORE, MALLORY STARR (CRNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:STARR
Last Name:DEVORE
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 1:42 HIGH MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-1853
Mailing Address - Country:US
Mailing Address - Phone:804-720-5361
Mailing Address - Fax:
Practice Address - Street 1:132 ABIGAIL LN
Practice Address - Street 2:
Practice Address - City:PORT MATILDA
Practice Address - State:PA
Practice Address - Zip Code:16870-7153
Practice Address - Country:US
Practice Address - Phone:814-272-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily