Provider Demographics
NPI:1306308309
Name:WILLIS, MALLORY LOUISE (DO)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LOUISE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:LOUISE
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1171 GATEWOOD DRIVE
Mailing Address - Street 2:#101
Mailing Address - City:AUBURN
Mailing Address - State:AL
Mailing Address - Zip Code:36830
Mailing Address - Country:US
Mailing Address - Phone:334-821-2708
Mailing Address - Fax:334-528-5420
Practice Address - Street 1:1171 GATEWOOD DRIVE
Practice Address - Street 2:#101
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36830
Practice Address - Country:US
Practice Address - Phone:334-821-2708
Practice Address - Fax:334-528-5420
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2943207Q00000X
171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2943OtherALABAMA MEDICAL LICENSE
AL2943OtherALABAMA MEDICAL LICENSE