Basic Information
| Provider Information | |||||||||
| NPI: | 1700390721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWNOVER | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | GAIL | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 S 52ND PL | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974786210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417461166 | ||||||||
| FaxNumber: | 5413931607 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 S 52ND PL | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974786210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417461166 | ||||||||
| FaxNumber: | 5413931607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363L00000X | ARNP9344290 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 201710156NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.