Healthcare Provider Details

I. General information

NPI: 1760120562
Provider Name (Legal Business Name): MALORI NEWBURY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2022
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6294 STATE HIGHWAY 154
SESSER IL
62884-2163
US

IV. Provider business mailing address

PO BOX 155
CHRISTOPHER IL
62822-0155
US

V. Phone/Fax

Practice location:
  • Phone: 618-625-6979
  • Fax: 618-625-6549
Mailing address:
  • Phone: 618-724-2401
  • Fax: 618-724-8792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025220
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: