Provider Demographics
NPI:1922498997
Name:HEINEY, MALLORY
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:HEINEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1175
Mailing Address - Country:US
Mailing Address - Phone:231-349-1044
Mailing Address - Fax:
Practice Address - Street 1:729 CLARK ST
Practice Address - Street 2:
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1175
Practice Address - Country:US
Practice Address - Phone:231-349-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114226164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse