Basic Information
| Provider Information | |||||||||
| NPI: | 1073235446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | RACHELLE | ||||||||
| MiddleName: | ELVINA CALDWELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALDWELL | ||||||||
| OtherFirstName: | RACHELLE | ||||||||
| OtherMiddleName: | ELVINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2348 S PASEO LOMA CIR | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852026444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806860003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 855 W 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804721070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | RN167426 | AZ | Y | Nursing Service Providers | Registered Nurse | School |
No ID Information.