Provider Demographics
NPI:1720830102
Name:WILLIS, MALLORIE LEIGH (CNM)
Entity Type:Individual
Prefix:MRS
First Name:MALLORIE
Middle Name:LEIGH
Last Name:WILLIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 WEBB LN
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40006-8746
Mailing Address - Country:US
Mailing Address - Phone:502-663-1873
Mailing Address - Fax:
Practice Address - Street 1:4123 DUTCHMANS LN STE 507
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4730
Practice Address - Country:US
Practice Address - Phone:502-423-9595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4018099176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife