MEDICARE: MALLORY R. WALTRIP APRN

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	363LA2200X	Adult Health Nurse Practitioner	209015762	IL
2	363LG0600X	Gerontology Nurse Practitioner	209015762	IL

General Provider Information

NPI Number	:	1780125278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY R. WALTRIP APRN

Provider Business Mailing Address
First Line	:	1025 S 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2403
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 N 1ST ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62702-3749
Country	:	US
Telephone Number	:	217-528-7541
Fax Number	:

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

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	04/07/2026

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