Provider Demographics
NPI:1992384507
Name:MALLORY, KRISTIN LAUREN (NP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LAUREN
Last Name:MALLORY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1698 VERNON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4100
Mailing Address - Country:US
Mailing Address - Phone:706-298-4937
Mailing Address - Fax:706-812-4157
Practice Address - Street 1:1698 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4100
Practice Address - Country:US
Practice Address - Phone:706-298-4937
Practice Address - Fax:706-812-4157
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN236013363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine