1720830102 NPI number — MRS. MALLORIE LEIGH WILLIS APRN, CNM

Table of content: MRS. MALLORIE LEIGH WILLIS APRN, CNM (NPI 1720830102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720830102 NPI number — MRS. MALLORIE LEIGH WILLIS APRN, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
MALLORIE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEAN
Provider Other First Name:
MALLORIE
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BSN, RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720830102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4123 DUTCHMANS LN STE 507
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-423-9595
Provider Business Practice Location Address Fax Number:
502-719-0161
Provider Enumeration Date:
04/01/2024

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: 367A00000X , with the licence number:  CNM9215 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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