Healthcare Provider Details

I. General information

NPI: 1780059030
Provider Name (Legal Business Name): MALLORY FOSSA PNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

3701 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90010-2814
US

V. Phone/Fax

Practice location:
  • Phone: 860-837-5207
  • Fax:
Mailing address:
  • Phone: 323-361-3550
  • Fax: 323-361-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95003548
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number12.008276
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number95003548
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: