Basic Information
| Provider Information | |||||||||
| NPI: | 1801540646 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE BOOM | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | QUINN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2044 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381012044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015076600 | ||||||||
| FaxNumber: | 9015076599 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 UNION AVE STE 495 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381046656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015076600 | ||||||||
| FaxNumber: | 9015076599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2022 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1191302 | 01 | TN | NCCPA CERTIFICATION | OTHER |