Provider Demographics
NPI:1083979033
Name:SIMON, MANDY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNN
Last Name:SIMON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:LYNN
Other - Last Name:MALOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 171247
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02117-1477
Mailing Address - Country:US
Mailing Address - Phone:857-294-7245
Mailing Address - Fax:
Practice Address - Street 1:166 SOUTH ST
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-5402
Practice Address - Country:US
Practice Address - Phone:857-294-7245
Practice Address - Fax:857-294-7245
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-05
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2265668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily