Provider Demographics
NPI:1770105199
Name:ALLEN, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:ALLEN
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 1:2427 HIGHWAY 6 NW
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:IA
Mailing Address - Zip Code:52340-9395
Mailing Address - Country:US
Mailing Address - Phone:319-321-1112
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2209
Practice Address - Country:US
Practice Address - Phone:058-131-9338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program