Provider Demographics
NPI:1255009056
Name:FREEMAN, MALLORY ALEXIS (APRN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ALEXIS
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 LURTON ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1307
Mailing Address - Country:US
Mailing Address - Phone:203-212-7592
Mailing Address - Fax:
Practice Address - Street 1:764 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3786
Practice Address - Country:US
Practice Address - Phone:203-443-9500
Practice Address - Fax:203-902-0509
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10018363LF0000X
CT126588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily