Basic Information
| Provider Information | |||||||||
| NPI: | 1780059030 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FOSSA | ||||||||
| FirstName: | MALLORY | ||||||||
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| Credential: | PNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900102814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233613550 | ||||||||
| FaxNumber: | 3233618502 | ||||||||
| Practice Location | |||||||||
| Address1: | 282 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608375207 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 95003548 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 12.008276 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 207LP3000X | 95003548 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
No ID Information.