Healthcare Provider Details

I. General information

NPI: 1255009056
Provider Name (Legal Business Name): MALLORY ALEXIS FREEMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 MILL ST
EAST BERLIN CT
06023-1159
US

IV. Provider business mailing address

9 ARNOLD DR
EAST HARTFORD CT
06108-2909
US

V. Phone/Fax

Practice location:
  • Phone: 860-348-5650
  • Fax: 860-855-7708
Mailing address:
  • Phone: 860-348-5650
  • Fax: 860-855-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10018
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number126588
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10018
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: