Provider Demographics
NPI:1073942546
Name:FEARON, NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FEARON
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 1:99 BEAMAN BRK
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-4005
Mailing Address - Country:US
Mailing Address - Phone:860-371-6636
Mailing Address - Fax:
Practice Address - Street 1:2639 MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2023
Practice Address - Country:US
Practice Address - Phone:860-659-1329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005480363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily