NPIMap

Individual provider Active NPI

Mallory Lynn Park, MSN, CRNP, FNP-C

  • General Practice Physician
  • Ridgway, PA
National Provider Identifier
1114755345
Registry record updated Jul 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
License
SP030067 Issued in PA
Practice address
250 W Main St
Ridgway, PA 15853-1611
Phone
(814) 772-8122
NPI assigned
Jul 22, 2024
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X SP030067 PA
General Practice Physician 208D00000X SP030067 PA Primary

Addresses

Primary practice location

250 W Main St
Ridgway, PA 15853-1611

Mailing address

101 Jenks St
Brookville, PA 15825-2303

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20241115004072 PA Practitioner - Nurse Practitioner 1557895257 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Dubois Regional Medical CenterGroup PAC ID 5890689715, 424 clinicians
Wellnow Urgent Care, P.C.Group PAC ID 8325320864, 395 clinicians

Practice addresses (Care Compare)

250 W Main St
Penn Highlands Family Medicine Ridgway
Ridgway, PA 15853-1611
Phone (814) 772-8122

917 S Saint Marys St
Saint Marys, PA 15857-2828
Phone (814) 389-1026

Hospital & facility affiliations

  • Penn Highlands Dubois Hospital, Dubois, PA, CCN 390086
  • Penn Highlands Elk Hospital, Saint Marys, PA, CCN 391315

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Master of Science - Nursing, Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Dubois Regional Medical Center Family Medicine CurrentSince Oct 1, 2024 Accepting new patients
Dubois Regional Medical Center CurrentSince Oct 1, 2024 Accepting new patients
Wellnow Urgent Care, PC CurrentSince Sep 29, 2025 Accepting new patients
Wellnow Urgent Care, PC PastSince Sep 29, 2025 Accepting new patients
Dubois Regional Medical Center Past Accepting new patients

Locations

26 Bolivar Dr
Bradford, PA 16701
Phone (814) 817-4690

100 Hospital Ave
Dubois, PA 15801
Phone (814) 375-2040

250 W Main St
Ridgway, PA 15853
Phone (814) 772-8122

917 S Saint Marys St
Saint Marys, PA 15857
Phone (814) 389-1026

761 Johnsonburg Rd
Ste 160
Saint Marys, PA 15857
Phone (814) 788-8777

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 29

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 29

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1721606400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1721606400000",
    "number": "1114755345",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 JENKS ST",
            "city": "BROOKVILLE",
            "state": "PA",
            "postal_code": "158252303"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "250 W MAIN ST",
            "city": "RIDGWAY",
            "state": "PA",
            "postal_code": "158531611",
            "telephone_number": "814-772-8122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PARK",
        "first_name": "MALLORY",
        "middle_name": "LYNN",
        "credential": "MSN, CRNP, FNP-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-07-22",
        "last_updated": "2024-07-22",
        "certification_date": "2024-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "PA",
            "license": "SP030067",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "PA",
            "license": "SP030067",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Ridgway, PA

Sources for this page

Verify at the official NPI Registry.