| NPI | 1669094231 |
|---|---|
| Former Name | MALLORY NICOLE WIDECAN |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.0027391) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2020-05-17 |
| Last Update Date | 2022-05-17 |