Provider Demographics
NPI:1043792641
Name:KLOCKE, MALLORY MARIE (CNM)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:KLOCKE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7060 N GREENVIEW AVE APT 2N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2831
Mailing Address - Country:US
Mailing Address - Phone:712-210-2717
Mailing Address - Fax:
Practice Address - Street 1:17 N STATE ST STE 500
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3384
Practice Address - Country:US
Practice Address - Phone:712-210-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017990367A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife