Provider Demographics
NPI:1417958364
Name:BALDINO, MARY ELLEN (APRN)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:BALDINO
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 1:333 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3206
Mailing Address - Country:US
Mailing Address - Phone:203-200-2255
Mailing Address - Fax:
Practice Address - Street 1:333 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-200-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3128363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004246494Medicaid
CT500001352Medicare ID - Type Unspecified
Q28387Medicare UPIN