Provider Demographics
NPI:1962074245
Name:MALLERY, CHEYENNE MICHELE (RN)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:MICHELE
Last Name:MALLERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 STATE ROUTE 17
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:IL
Mailing Address - Zip Code:61449-9623
Mailing Address - Country:US
Mailing Address - Phone:309-854-2579
Mailing Address - Fax:
Practice Address - Street 1:2359 STATE ROUTE 17
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:IL
Practice Address - Zip Code:61449-9623
Practice Address - Country:US
Practice Address - Phone:309-854-2579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA143858163W00000X
TX1020215163W00000X
IL041436220163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse