Basic Information
| Provider Information | |||||||||
| NPI: | 1427458553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOWDY | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 186 BURRIS RD SE | ||||||||
| Address2: | |||||||||
| City: | MC CALL CREEK | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396475295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017300602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 290 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018257280 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2014 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R877141 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.