Provider Demographics
NPI:1073676748
Name:OBEREMBT, MARY ANN (MS BC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:OBEREMBT
Suffix:
Gender:F
Credentials:MS BC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:LAGASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 JORDAN LN
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-1278
Mailing Address - Country:US
Mailing Address - Phone:860-263-0253
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:357 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-2540
Practice Address - Country:US
Practice Address - Phone:860-296-4022
Practice Address - Fax:860-296-5015
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001354363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000233Medicare ID - Type Unspecified
CTS78434Medicare UPIN