Provider Demographics
NPI:1720614456
Name:MALLON, STACIE M (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:M
Last Name:MALLON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:SLATER
Mailing Address - State:IA
Mailing Address - Zip Code:50244-0276
Mailing Address - Country:US
Mailing Address - Phone:515-490-9739
Mailing Address - Fax:
Practice Address - Street 1:30865 130TH CT
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:IA
Practice Address - Zip Code:50276-6209
Practice Address - Country:US
Practice Address - Phone:515-490-9739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA157443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily