Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | IL |
NPI | 1083277404 |
---|---|
Provider Name | Malory Rebekah Teegarden |
First Address | Peoria, IL 61604-1516 |
Second Address | Peoria, IL 61604-1516 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2019 |
Last Update Date | 20/03/2020 |