Provider Demographics
NPI:1659469310
Name:MAULT, HOLLY ELLEN (ANP, FNP)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ELLEN
Last Name:MAULT
Suffix:
Gender:F
Credentials:ANP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1814
Mailing Address - Country:US
Mailing Address - Phone:845-782-6298
Mailing Address - Fax:
Practice Address - Street 1:45 FOSTER RD
Practice Address - Street 2:
Practice Address - City:HOPEWELL JUNCTION
Practice Address - State:NY
Practice Address - Zip Code:12533-6123
Practice Address - Country:US
Practice Address - Phone:845-226-4590
Practice Address - Fax:845-226-2465
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304327363LA2200X
NY337423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health