Basic Information
| Provider Information | |||||||||
| NPI: | 1508273590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURSLEY | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARKIEWICZ | ||||||||
| OtherFirstName: | MALLORY | ||||||||
| OtherMiddleName: | LOUISE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1608 SOUTH J STREET | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532747503 | ||||||||
| FaxNumber: | 2532747993 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 SUNNYVIEW LN | ||||||||
| Address2: | |||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067521790 | ||||||||
| FaxNumber: | 4067563529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2014 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60485703 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | NUR-APRN-LIC-198535 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.