Individual
DR. MALLORY WEAVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
815 MAIN ST STE C, PEORIA, IL 61602-1080
(309) 672-4977
Mailing address
1179 N BLUFF LAKE DR, EAST PEORIA, IL 61611-1281
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
90200000X
—
Other
Enumeration date
05/23/2023
Last updated
05/23/2023
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