Provider Demographics
NPI:1174389357
Name:ANDERSON, MALLORY (CNM)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4959 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIB LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54470-9727
Mailing Address - Country:US
Mailing Address - Phone:715-965-6993
Mailing Address - Fax:
Practice Address - Street 1:N4959 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIB LAKE
Practice Address - State:WI
Practice Address - Zip Code:54470-9727
Practice Address - Country:US
Practice Address - Phone:715-965-6993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI150053367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty