Provider Demographics
NPI:1740797398
Name:BATES, MALLORY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELIZABETH
Last Name:BATES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3735
Mailing Address - Country:US
Mailing Address - Phone:636-236-5602
Mailing Address - Fax:
Practice Address - Street 1:224 S WOODS MILL RD STE 330S
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3497
Practice Address - Country:US
Practice Address - Phone:143-576-7013
Practice Address - Fax:314-576-4047
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018004643363LA2200X, 363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program