Provider Demographics
NPI:1043856701
Name:HENSON, MALLORY JEAN (PA)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:JEAN
Last Name:HENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:JEAN
Other - Last Name:STIMAC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:12855 N 40 DR STE 375
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8657
Mailing Address - Country:US
Mailing Address - Phone:314-567-6071
Mailing Address - Fax:
Practice Address - Street 1:6800 STATE ROUTE 162 STE 200
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8521
Practice Address - Country:US
Practice Address - Phone:618-288-0900
Practice Address - Fax:618-288-0909
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant