Provider Demographics
NPI:1982410528
Name:HUMPHREY, MALLORY KAY (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAY
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:KAY
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2705
Mailing Address - Country:US
Mailing Address - Phone:419-961-3136
Mailing Address - Fax:
Practice Address - Street 1:600 W 3RD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2633
Practice Address - Country:US
Practice Address - Phone:419-522-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0037747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily