Provider Demographics
NPI:1548728249
Name:SHATLOCK, MALLORY RICH (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:RICH
Last Name:SHATLOCK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-765-6637
Mailing Address - Fax:336-765-6964
Practice Address - Street 1:190 KIMEL PARK DR STE 155
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-765-6637
Practice Address - Fax:336-765-6964
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-159191363LA2100X
NC5021115363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care