MEDICARE: MALLORY MARIE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	000963	IA

General Provider Information

NPI Number	:	1073930723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY MARIE WILSON

Provider Business Mailing Address
First Line	:	502 E MARKET ST
Second Line	:
City	:	NEW SHARON
State	:	IA
Zip	:	50207-9757
Country	:	US
Telephone Number	:	641-895-1478
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 E MARKET ST
Second Line	:
City	:	NEW SHARON
State	:	IA
Zip	:	50207-9757
Country	:	US
Telephone Number	:	641-895-1478
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2014
Last Update Date	:	03/19/2014

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Directions to “ MALLORY MARIE WILSON ” Practice Location

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