Healthcare Provider Details

I. General information

NPI: 1811833841
Provider Name (Legal Business Name): MALLORY SALIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3134 N CLARK ST
CHICAGO IL
60657-4414
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 312-766-4949
  • Fax:
Mailing address:
  • Phone: 847-390-5901
  • Fax: 847-390-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.033081
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: