Healthcare Provider Details

I. General information

NPI: 1891585600
Provider Name (Legal Business Name): MALLORY ELISE FREEMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY ELISE BENJAMIN RN

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WASHINGTON ST
ELMIRA NY
14901-2849
US

IV. Provider business mailing address

132 W 10TH ST
ELMIRA HEIGHTS NY
14903-1617
US

V. Phone/Fax

Practice location:
  • Phone: 607-737-4700
  • Fax:
Mailing address:
  • Phone: 607-481-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number738099-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: