Provider Demographics
NPI:1174510440
Name:LAWRENCE-RIDDELL, JANE (APRN)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:
Last Name:LAWRENCE-RIDDELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:MAXFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 LONG WHARF DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5991
Mailing Address - Country:US
Mailing Address - Phone:203-865-3737
Mailing Address - Fax:203-624-0751
Practice Address - Street 1:1 LONG WHARF DR
Practice Address - Street 2:SUITE 105
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-865-3737
Practice Address - Fax:203-624-0751
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002336363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics