Provider Demographics
NPI:1952296972
Name:WILLIAMS, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WILLIAMS
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 1:1611 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855-7539
Mailing Address - Country:US
Mailing Address - Phone:662-871-9914
Mailing Address - Fax:
Practice Address - Street 1:1611 RIVER RD
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855-7539
Practice Address - Country:US
Practice Address - Phone:662-871-9914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program