Provider Demographics
NPI:1881108462
Name:WILLETT, MALLORY ELISE
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ELISE
Last Name:WILLETT
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 1:1200 INGHAM ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-2840
Mailing Address - Country:US
Mailing Address - Phone:724-263-0741
Mailing Address - Fax:
Practice Address - Street 1:611 DUNCAN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5854
Practice Address - Country:US
Practice Address - Phone:412-358-8690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-19
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018132363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily