Provider Demographics
NPI:1720830102
Name:WILLIS, MALLORIE LEIGH (APRN, CNM)
Entity type:Individual
Prefix:MRS
First Name:MALLORIE
Middle Name:LEIGH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:MALLORIE
Other - Middle Name:LEIGH
Other - Last Name:DEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4123 DUTCHMANS LN STE 507
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4730
Practice Address - Country:US
Practice Address - Phone:502-423-9595
Practice Address - Fax:502-719-0161
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYCNM9215367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife