Healthcare Provider Details

I. General information

NPI: 1093244162
Provider Name (Legal Business Name): MALLORY A SIMONTON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY A COOK FNP

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PHIPPS LN
PARIS IL
61944-2919
US

IV. Provider business mailing address

2200 S MAIN ST
PARIS IL
61944-2966
US

V. Phone/Fax

Practice location:
  • Phone: 217-463-4340
  • Fax:
Mailing address:
  • Phone: 217-463-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007144A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018013
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: