Provider Demographics
NPI:1063492452
Name:RICHARDSON, LORETTA C (CNM)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:C
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:860-307-2937
Mailing Address - Fax:203-754-0788
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:860-307-2937
Practice Address - Fax:203-754-0788
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2340005367A00000X
CT000166367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004209509Medicaid
CT1063492452Medicaid
CT1063492452Medicaid