Provider Demographics
NPI:1477547404
Name:BREKUS-WATSON, CAROL (CNM)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:
Last Name:BREKUS-WATSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 HICKORY LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1718
Mailing Address - Country:US
Mailing Address - Phone:203-421-4153
Mailing Address - Fax:
Practice Address - Street 1:687 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3612
Practice Address - Country:US
Practice Address - Phone:203-488-8306
Practice Address - Fax:203-481-0267
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000008367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT420000034Medicare PIN