Provider Demographics
NPI:1093959397
Name:MENICK, SUANNE M (APRN)
Entity Type:Individual
Prefix:
First Name:SUANNE
Middle Name:M
Last Name:MENICK
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 1:282 WASHINGTON ST
Mailing Address - Street 2:NICU
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-8950
Mailing Address - Fax:860-545-8945
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:NICU
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-8950
Practice Address - Fax:860-545-8945
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0030379363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1215947387Medicaid