Provider Demographics
NPI:1629854914
Name:ELLER, MALLORY KAYDEE (RN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:KAYDEE
Last Name:ELLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-2029
Mailing Address - Country:US
Mailing Address - Phone:765-480-2655
Mailing Address - Fax:
Practice Address - Street 1:537 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2029
Practice Address - Country:US
Practice Address - Phone:765-480-2655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28240957A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse