Provider Demographics
NPI:1982082293
Name:GROSSMAN, MALLORY A (NP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2024 DORCHESTER CT STE 1
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2024 DORCHESTER CT STE 1
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6546
Practice Address - Country:US
Practice Address - Phone:574-537-8326
Practice Address - Fax:574-534-1034
Is Sole Proprietor?:No
Enumeration Date:2015-05-07
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005825A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN184520036Medicare PIN