1508273590 NPI number — MALLORY LOUISE PURSLEY ARNP

Table of content: MALLORY LOUISE PURSLEY ARNP (NPI 1508273590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508273590 NPI number — MALLORY LOUISE PURSLEY ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURSLEY
Provider First Name:
MALLORY
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARKIEWICZ
Provider Other First Name:
MALLORY
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508273590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 SOUTH J STREET
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-274-7503
Provider Business Mailing Address Fax Number:
253-274-7993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 SUNNYVIEW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-3156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-1790
Provider Business Practice Location Address Fax Number:
406-756-3529
Provider Enumeration Date:
07/22/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  NUR-APRN-LIC-198535 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: AP60485703 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)