Provider Demographics
NPI:1538789169
Name:SIMON, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:SIMON
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 1:6123A LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-1326
Mailing Address - Country:US
Mailing Address - Phone:616-438-2531
Mailing Address - Fax:
Practice Address - Street 1:5005 MARYLAND WAY
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-7545
Practice Address - Country:US
Practice Address - Phone:615-846-8269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily