Basic Information
| Provider Information | |||||||||
| NPI: | 1609334630 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 PARNASSUS AVE | ||||||||
| Address2: | M-917 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153531116 | ||||||||
| FaxNumber: | 4153531990 | ||||||||
| Practice Location | |||||||||
| Address1: | 1485 RIVER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958154530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163251040 | ||||||||
| FaxNumber: | 9166694100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2019 | ||||||||
| LastUpdateDate: | 01/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LC0200X | 95014580 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.