Provider Demographics
NPI:1730607615
Name:SMITH, MALLORI (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORI
Other - Middle Name:
Other - Last Name:JACKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 426
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-0426
Mailing Address - Country:US
Mailing Address - Phone:620-432-5588
Mailing Address - Fax:620-431-1192
Practice Address - Street 1:1501 W 7TH ST STE 2
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-2516
Practice Address - Country:US
Practice Address - Phone:620-432-5588
Practice Address - Fax:620-431-1192
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant