Provider Demographics
NPI:1144861089
Name:SUPLEY, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SUPLEY
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:PO BOX 234
Mailing Address - Street 2:
Mailing Address - City:CADYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12918-0234
Mailing Address - Country:US
Mailing Address - Phone:518-293-5038
Mailing Address - Fax:
Practice Address - Street 1:70 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1537
Practice Address - Country:US
Practice Address - Phone:518-891-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303566164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse