Individual
CAROLYN T MALLILLIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1900 BLUEGRASS AVE STE 300, LOUISVILLE, KY 40215-1183
(502) 361-1222
Mailing address
174 CHINA BLUE LN, CAPE GIRARDEAU, MO 63701-3800
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
45207
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34336500
—
WI
Enumeration date
09/07/2005
Last updated
01/14/2021
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