=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649953449
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLORIE ALLEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2023
-----------------------------------------------------
Last Update Date | 05/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 W MADISON ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61832-5657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-431-7850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 W PARK ST FAPC
-----------------------------------------------------
City | URBANA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61801-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209.028003
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------