Healthcare Provider Details

I. General information

NPI: 1174168686
Provider Name (Legal Business Name): MALLORY ROCHON SIMMONS DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

IV. Provider business mailing address

251 E HURON ST STE 5-704
CHICAGO IL
60611-2908
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-8369
  • Fax: 312-926-8341
Mailing address:
  • Phone: 312-926-8369
  • Fax: 312-926-8341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2021031891
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209029505
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number206869
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number810213
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: