Provider Demographics
NPI:1104355510
Name:FOCHTMAN, MALLORY SHAE (CNP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SHAE
Last Name:FOCHTMAN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:STONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:2006 CABERNET WAY
Mailing Address - Street 2:
Mailing Address - City:BELLBROOK
Mailing Address - State:OH
Mailing Address - Zip Code:45305-7502
Mailing Address - Country:US
Mailing Address - Phone:719-258-0848
Mailing Address - Fax:
Practice Address - Street 1:2006 CABERNET WAY
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-7502
Practice Address - Country:US
Practice Address - Phone:719-258-0848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0035041363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health