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General NPI Number Information
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NPI Number | 1245800937
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Entity Type | Individual
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Provider Name | MALLORY JANE SHERIDAN PA-C
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Gender | Female
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Dates
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Enumeration Date | 06/25/2021
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Last Update Date | 05/28/2025
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Provider Practice Location Address
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Address Line | 16826 NEWBURGH RD
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City | LIVONIA
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State | MI
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Zip | 48154-1600
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Country | US
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Telephone | 734-464-8400
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Fax | 734-464-9515
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Provider Business Mailing Address
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Address Line | 3021 BIRCH ROW DR APT 14
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City | EAST LANSING
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State | MI
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Zip | 48823-2295
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Country | US
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Telephone | 231-675-7250
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601010628
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License Number State | MI
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