1275151623 NPI number — MRS. MALLORY CLARE STORRS MBA, RD, LD

Table of content: MRS. MALLORY CLARE STORRS MBA, RD, LD (NPI 1275151623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275151623 NPI number — MRS. MALLORY CLARE STORRS MBA, RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STORRS
Provider First Name:
MALLORY
Provider Middle Name:
CLARE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MBA, RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PIONTKOWSKI
Provider Other First Name:
MALLORY
Provider Other Middle Name:
CLARE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275151623
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6112 W 123RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALOS HEIGHTS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60463-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-341-8789
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10631 PALOS WEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOS PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60464-1598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-341-8789
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  164005527 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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