Provider Demographics
NPI:1801783402
Name:MUMMA, MALLORY R (AGPCNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:R
Last Name:MUMMA
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 EBBETS DR SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-4606
Mailing Address - Country:US
Mailing Address - Phone:503-805-0845
Mailing Address - Fax:
Practice Address - Street 1:209 LILLY RD NE STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5030
Practice Address - Country:US
Practice Address - Phone:360-413-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60412207163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology