Provider Demographics
NPI:1699131961
Name:CANTERO, MALLORY K
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:K
Last Name:CANTERO
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 1:2003 TULANE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-3500
Mailing Address - Country:US
Mailing Address - Phone:504-962-6120
Mailing Address - Fax:
Practice Address - Street 1:2003 TULANE AVE
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-3500
Practice Address - Country:US
Practice Address - Phone:504-962-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-02
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08651363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
507891Medicare PIN