Basic Information
Provider Information | |||||||||
NPI: | 1780177139 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | MALLORY | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1088 LONDON LINKS DR | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 245514662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345346868 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1088 LONDON LINKS DR | ||||||||
Address2: |   | ||||||||
City: | FOREST | ||||||||
State: | VA | ||||||||
PostalCode: | 245514662 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4345346868 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2018 | ||||||||
LastUpdateDate: | 07/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1099751665 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 390200000X | 0116031806 | VA | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.