Provider Demographics
NPI:1912660762
Name:EARTHMAN, MALLORY LYN (APRN)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LYN
Last Name:EARTHMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 US HWY 75
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-4584
Mailing Address - Country:US
Mailing Address - Phone:903-416-4100
Mailing Address - Fax:
Practice Address - Street 1:5016 US HWY 75
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-4584
Practice Address - Country:US
Practice Address - Phone:903-416-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1057092363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner