Provider Demographics
NPI:1861751463
Name:MALLORY, NICOLE SARELL (PT, DPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:SARELL
Last Name:MALLORY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:SARELL
Other - Last Name:SAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 306393
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6393
Mailing Address - Country:US
Mailing Address - Phone:615-373-1350
Mailing Address - Fax:615-373-7116
Practice Address - Street 1:875 W POPLAR AVE STE 18
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2568
Practice Address - Country:US
Practice Address - Phone:901-850-5742
Practice Address - Fax:901-850-5701
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN225100000X
WA602488822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer