Provider Demographics
NPI:1255094868
Name:MALLORY, KALLIE D (BS, AS)
Entity Type:Individual
Prefix:MRS
First Name:KALLIE
Middle Name:D
Last Name:MALLORY
Suffix:
Gender:F
Credentials:BS, AS
Other - Prefix:MISS
Other - First Name:KALLIE
Other - Middle Name:D
Other - Last Name:SIDDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:517 COURT ST RM 503
Mailing Address - Street 2:
Mailing Address - City:NEILLSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54456-1976
Mailing Address - Country:US
Mailing Address - Phone:715-743-5191
Mailing Address - Fax:715-743-5209
Practice Address - Street 1:517 COURT ST RM 503
Practice Address - Street 2:
Practice Address - City:NEILLSVILLE
Practice Address - State:WI
Practice Address - Zip Code:54456-1976
Practice Address - Country:US
Practice Address - Phone:715-743-5191
Practice Address - Fax:715-743-5209
Is Sole Proprietor?:No
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator