Healthcare Provider Details

I. General information

NPI: 1982969440
Provider Name (Legal Business Name): JULIE A MALLON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 MOUNT AUBURN ST
CAMBRIDGE MA
02138-5502
US

IV. Provider business mailing address

330 MOUNT AUBURN ST SUITE 110
CAMBRIDGE MA
02138-5502
US

V. Phone/Fax

Practice location:
  • Phone: 617-499-5055
  • Fax: 617-499-5045
Mailing address:
  • Phone: 781-391-2705
  • Fax: 781-395-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2263049
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: