Provider Demographics
NPI:1669187902
Name:BOYLE, MALLORY (CRNP, RN)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:BOYLE
Suffix:
Gender:F
Credentials:CRNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:HADDON TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2316
Mailing Address - Country:US
Mailing Address - Phone:856-904-9753
Mailing Address - Fax:
Practice Address - Street 1:822 PINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6187
Practice Address - Country:US
Practice Address - Phone:267-519-0154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR22832300163W00000X
PARN685967163W00000X
PASP027836363LF0000X
NJ26NJ01457800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse