Provider Demographics
NPI:1629734751
Name:COOLIDGE, MALLORY MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:MARIE
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11461 BAUMAN AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-6815
Mailing Address - Country:US
Mailing Address - Phone:402-640-5722
Mailing Address - Fax:
Practice Address - Street 1:8141 W CENTER RD STE 200
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3273
Practice Address - Country:US
Practice Address - Phone:402-717-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE113809363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner