Provider Demographics
NPI:1174387773
Name:CHIANG, MALLORY IRENE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:IRENE
Last Name:CHIANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-256-2754
Mailing Address - Fax:
Practice Address - Street 1:200 BLUE MOON XING STE 203
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9698
Practice Address - Country:US
Practice Address - Phone:912-590-0973
Practice Address - Fax:912-590-0180
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant