Provider Demographics
NPI:1538618335
Name:MALLORY, SHEILA (FNP-C)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:MALLORY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SYLVAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1548
Mailing Address - Country:US
Mailing Address - Phone:770-775-4540
Mailing Address - Fax:770-775-4078
Practice Address - Street 1:146 SYLVAN DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1548
Practice Address - Country:US
Practice Address - Phone:770-775-4540
Practice Address - Fax:770-775-4078
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily