Healthcare Provider Details

I. General information

NPI: 1942145537
Provider Name (Legal Business Name): MALLORY WENDY MADDEN PERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY WENDY MADDEN

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MEDICAL PLAZA DR STE 200
ROSEVILLE CA
95661-3088
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-773-8750
  • Fax:
Mailing address:
  • Phone: 800-470-0071
  • Fax: 916-854-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95040260
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: