Provider Demographics
NPI:1497592778
Name:WILSON, MALLORY (CNM)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WILSON
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 1:3101 SHIPPERS RD STE 106
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2081
Mailing Address - Country:US
Mailing Address - Phone:607-644-4585
Mailing Address - Fax:
Practice Address - Street 1:3101 SHIPPERS RD STE 106
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2081
Practice Address - Country:US
Practice Address - Phone:607-584-4549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002309176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife