Mallory Moody Putnam, PA
Physician Assistant, Medical in Lakeland, FL. Individual provider (NPI-1).
NPI number1336493428
StatusActive
Last updated in NPPESJan 30, 2017
Details
- NPI
- 1336493428
- Entity type
- Individual (NPI-1)
- Name
- Mrs. Mallory Moody Putnam
- Credential
- PA
- Sex
- Female
- Sole proprietor
- Yes
- Enumeration date
- Oct 29, 2012
- Last updated
- Jan 30, 2017
Medicare and OIG
- Medicare enrolled (PECOS)
- Yes · PRACTITIONER - PHYSICIAN ASSISTANT
- Can order and refer
- Part B Yes · DME Yes · Home health Yes · Power mobility Yes · Hospice No
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363AM0700X | Physician Assistant, Medical | PA9106745 | FL | Yes |
Practice location
2615 Fairmount AveLakeland, FL 33803-3159
Phone 863-661-3887
Mailing address
1324 Lakeland Hills BlvdLakeland, FL 33805-4543
Phone 863-687-1100
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