Provider Demographics
NPI:1346231347
Name:TILSON-MALLETT, NANCY R (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:R
Last Name:TILSON-MALLETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:R
Other - Last Name:TILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2310 HOLMES ST
Mailing Address - Street 2:STE 800
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-2602
Mailing Address - Country:US
Mailing Address - Phone:816-218-2500
Mailing Address - Fax:
Practice Address - Street 1:7900 LEES SUMMIT RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64139-1236
Practice Address - Country:US
Practice Address - Phone:816-404-6660
Practice Address - Fax:816-404-6661
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2K27207R00000X
KS04-23033207R00000X
MO2013039025208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202938445Medicaid
MOE23390Medicare UPIN