Provider Demographics
NPI:1407318637
Name:BIANCHI, DOMENICK (APRN)
Entity Type:Individual
Prefix:
First Name:DOMENICK
Middle Name:
Last Name:BIANCHI
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 1:103 STAFFORD ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4336
Mailing Address - Country:US
Mailing Address - Phone:413-455-6638
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:413-455-6638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8139363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care