Provider Demographics
NPI:1417045055
Name:GONCI, MARY-ELLEN A (APRN)
Entity Type:Individual
Prefix:
First Name:MARY-ELLEN
Middle Name:A
Last Name:GONCI
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:PO BOX 40,000 DEPT 634
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06151-0634
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL OB/GYN DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102
Practice Address - Country:US
Practice Address - Phone:860-545-2780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002958363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ56960Medicare UPIN