Provider Demographics
NPI:1093244162
Name:SIMONTON, MALLORY A (FNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:SIMONTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:A
Other - Last Name:COOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2200 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2966
Mailing Address - Country:US
Mailing Address - Phone:217-463-4340
Mailing Address - Fax:
Practice Address - Street 1:1 PHIPPS LN
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2919
Practice Address - Country:US
Practice Address - Phone:217-463-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007144A363LF0000X
IL209018013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71007144AOtherAPN LICENSE