Provider Demographics
NPI:1144816406
Name:HOOVER, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:HOOVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-4733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:IA
Practice Address - Zip Code:52641-3120
Practice Address - Country:US
Practice Address - Phone:319-984-4775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAF12200531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily