Provider Demographics
NPI:1508898800
Name:MICHAELSON, GRETCHEN TOUMA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:GRETCHEN
Middle Name:TOUMA
Last Name:MICHAELSON
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 1:185 PIERCE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2633
Mailing Address - Country:US
Mailing Address - Phone:860-805-7085
Mailing Address - Fax:
Practice Address - Street 1:1741 ELLINGTON RD STE 1
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-263-3603
Practice Address - Fax:860-254-6167
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT074698163WC0200X
MA241128163WC0200X
CT003107363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
030107OtherCONNECTICARE
2V5468OtherHEALTHNET
030107OtherCONNECTICARE
2V5468OtherHEALTHNET