Provider Demographics
NPI:1265786917
Name:BREITMAIER, MALLORY SIMPSON (FNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SIMPSON
Last Name:BREITMAIER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 LEAFWOOD LN
Mailing Address - Street 2:# 297
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6701
Mailing Address - Country:US
Mailing Address - Phone:401-714-5502
Mailing Address - Fax:
Practice Address - Street 1:119 S MAIN ST
Practice Address - Street 2:MINUTECLINIC
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1456
Practice Address - Country:US
Practice Address - Phone:401-714-5502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5210363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily