Provider Demographics
NPI:1417380858
Name:ROCKEFELLER, JEANNINE M (APRN)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:M
Last Name:ROCKEFELLER
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 1:53 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06471-1254
Mailing Address - Country:US
Mailing Address - Phone:203-464-1369
Mailing Address - Fax:
Practice Address - Street 1:682 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2907
Practice Address - Country:US
Practice Address - Phone:203-481-5591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily