Provider Demographics
NPI:1376301283
Name:WOOD, MICHAEL VANCE (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VANCE
Last Name:WOOD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DEEPWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3155
Mailing Address - Country:US
Mailing Address - Phone:470-767-3029
Mailing Address - Fax:
Practice Address - Street 1:300 HEBRON AVE STE 203
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2192
Practice Address - Country:US
Practice Address - Phone:860-946-0447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12873363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health