Provider Demographics
NPI:1497578744
Name:VALDEZ, MALLORY KATHRYN (NP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:KATHRYN
Last Name:VALDEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:KATHRYN
Other - Last Name:MAROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1120 E MICHIGAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1810
Mailing Address - Country:US
Mailing Address - Phone:517-364-9777
Mailing Address - Fax:
Practice Address - Street 1:1120 E MICHIGAN AVE STE A
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1810
Practice Address - Country:US
Practice Address - Phone:517-364-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-05
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313499363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care