Provider Demographics
NPI:1073552865
Name:BRAY, DIANE M (APRN, BC)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:BRAY
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 NILES RD
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06057-2412
Mailing Address - Country:US
Mailing Address - Phone:860-379-7154
Mailing Address - Fax:
Practice Address - Street 1:664 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4203
Practice Address - Country:US
Practice Address - Phone:860-236-8087
Practice Address - Fax:860-586-7422
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000772364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4556305OtherAETNA
CTP1935240OtherOXFORD
CT188780OtherMHN
CT400000772-CT02OtherBLUE CROSS/ BLUE SHIELD
CT134533OtherVALUE OPTIONS
CT400000772-CT01OtherBLUE CROSS/ BLUE SHIELD
CT4556305OtherAETNA