Provider Demographics
NPI:1457691594
Name:WALES, MALLORY NICOLE (DC)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICOLE
Last Name:WALES
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1637 HUFFMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-2203
Mailing Address - Country:US
Mailing Address - Phone:269-207-9090
Mailing Address - Fax:
Practice Address - Street 1:26300 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0917
Practice Address - Country:US
Practice Address - Phone:248-546-2110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002702A111N00000X
MI2301010995111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor