Individual
MALLORY QUINN DE BOOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2004 EXETER RD, GERMANTOWN, TN 38138-3945
(901) 664-2111
Mailing address
20770 US HIGHWAY 281 N # 108-439, SAN ANTONIO, TX 78258-7655
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
4931
TN
363AM0700X
Medical Physician Assistant
—
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1191302
NCCPA CERTIFICATION
TN
Enumeration date
02/10/2022
Last updated
11/13/2024
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