Basic Information
| Provider Information | |||||||||
| NPI: | 1568431161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | THERESA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WILLARD STREET | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174791437 | ||||||||
| FaxNumber: | 6174793500 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 WILLARD STREET | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174791437 | ||||||||
| FaxNumber: | 6174793500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 128754 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | N318 | 01 | MA | HPHC | OTHER | 357472 | 05 | MA | MEDICAID | NP2083 | 01 | MA | BC/BS | OTHER |