Provider Demographics
NPI:1184204141
Name:SCHULTZ, MALLORY TAYLOR
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:TAYLOR
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 SCOTT SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-3124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 SCOTT SWAMP RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-3124
Practice Address - Country:US
Practice Address - Phone:860-751-6265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator