Provider Demographics
NPI:1760948178
Name:MERRILL, MALLORY BENKERT (DNP, NP-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BENKERT
Last Name:MERRILL
Suffix:
Gender:F
Credentials:DNP, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 PEMBROKE HL
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1461
Mailing Address - Country:US
Mailing Address - Phone:757-576-6944
Mailing Address - Fax:
Practice Address - Street 1:2400 TAMARACK AVE STE 101
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5556
Practice Address - Country:US
Practice Address - Phone:860-644-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8015363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health