Basic Information
| Provider Information | |||||||||
| NPI: | 1639417215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | MATHIS | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PNP, FNP, MSN, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 7TH AVE S # CPPNM20 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056389072 | ||||||||
| FaxNumber: | 2056382833 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 7TH AVE S # CPPNM20 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352331711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056389072 | ||||||||
| FaxNumber: | 2056382833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2013 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1-185381 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.