MEDICARE: MALLORY B HOMMERTZHEIM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	113578	OK
2	363LF0000X	Family Nurse Practitioner	1257	CO

General Provider Information

NPI Number	:	1073154787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY B HOMMERTZHEIM NP

Provider Business Mailing Address
First Line	:	595 CHAPEL HILLS DR STE 303B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1022
Country	:	US
Telephone Number	:	719-922-1002
Fax Number	:	719-888-1841

Provider Business Practice Location Address
First Line	:	595 CHAPEL HILLS DR STE 303B
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1022
Country	:	US
Telephone Number	:	719-922-1002
Fax Number	:	719-888-1841

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2019
Last Update Date	:	03/24/2026

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