Provider Demographics
NPI:1548079130
Name:MALLARI, MARY GRACE ANTONIETT (FNP-C)
Entity type:Individual
Prefix:
First Name:MARY GRACE ANTONIETT
Middle Name:
Last Name:MALLARI
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 1:22419 MARINE AVE
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-4048
Mailing Address - Country:US
Mailing Address - Phone:310-489-6436
Mailing Address - Fax:
Practice Address - Street 1:1300 N MISSION RD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1021
Practice Address - Country:US
Practice Address - Phone:323-409-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95033235363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty