Provider Demographics
NPI:1063487106
Name:YOUNG, MARY C (APRN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:YOUNG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WOODLAND STREET
Mailing Address - Street 2:NEONATAL INTENSIVE CARE
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-714-4404
Mailing Address - Fax:860-714-8218
Practice Address - Street 1:1000 ASYLUM AVE STE 2109A
Practice Address - Street 2:NEONATAL INTENSIVE CARE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1719
Practice Address - Country:US
Practice Address - Phone:860-714-6581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000953363LN0000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004254265Medicaid
P36959Medicare UPIN
CT004254265Medicaid