Provider Demographics
NPI:1174941892
Name:MUDD POMERVILLE, MALLORY DAWN (IBCLC, LPN)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:DAWN
Last Name:MUDD POMERVILLE
Suffix:
Gender:F
Credentials:IBCLC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1538 BOWFIN CT
Mailing Address - Street 2:UNIT D
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-6725
Mailing Address - Country:US
Mailing Address - Phone:660-909-2350
Mailing Address - Fax:
Practice Address - Street 1:1538 BOWFIN CT
Practice Address - Street 2:UNIT D
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-6725
Practice Address - Country:US
Practice Address - Phone:660-909-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL-41930163WL0100X
FLPN 5214349164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No164W00000XNursing Service ProvidersLicensed Practical Nurse