Provider Demographics
NPI:1073930723
Name:WILSON, MALLORY MARIE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:WILSON
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 1:502 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:NEW SHARON
Mailing Address - State:IA
Mailing Address - Zip Code:50207-9757
Mailing Address - Country:US
Mailing Address - Phone:641-895-1478
Mailing Address - Fax:
Practice Address - Street 1:502 E MARKET ST
Practice Address - Street 2:
Practice Address - City:NEW SHARON
Practice Address - State:IA
Practice Address - Zip Code:50207-9757
Practice Address - Country:US
Practice Address - Phone:641-895-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000963224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant