Provider Demographics
NPI:1609334630
Name:SMITH, MALLORY LYNNE (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 CAMPUS PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2308
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3900 KRESGE WAY STE 42
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4681
Practice Address - Country:US
Practice Address - Phone:502-899-3858
Practice Address - Fax:502-899-3878
Is Sole Proprietor?:No
Enumeration Date:2019-03-08
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4018626363LA2200X
TXAP140939363LA2200X
CA95014580363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100983120Medicaid