Provider Demographics
NPI:1487858361
Name:BROCKWELL, MELINDA ETHEL (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:ETHEL
Last Name:BROCKWELL
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 1:8 LOWLYN DR
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-1829
Mailing Address - Country:US
Mailing Address - Phone:203-226-0650
Mailing Address - Fax:203-852-3109
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3852
Practice Address - Country:US
Practice Address - Phone:203-852-2148
Practice Address - Fax:203-852-3109
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003545364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist