Healthcare Provider Details

I. General information

NPI: 1265399653
Provider Name (Legal Business Name): MALLORY ROSE HOLZER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 03/17/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14532 S OUTER 40 RD DEPT ORTHOPAEDIC SURGERY, STE 200
CHESTERFIELD MO
63017-5705
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-514-3500
  • Fax: 314-878-7678
Mailing address:
  • Phone: 314-514-3500
  • Fax: 314-878-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2026005852
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: