Provider Demographics
NPI:1659353118
Name:REVERE, MADELINE FRANCIS (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:FRANCIS
Last Name:REVERE
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 1:3 SABBADAY LN
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06793-1306
Mailing Address - Country:US
Mailing Address - Phone:860-868-0440
Mailing Address - Fax:203-573-7007
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:CRISIS INTERVENTION CENTER
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-6798
Practice Address - Fax:203-573-7007
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000241363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT890000386OtherMEDICARE ID- TYPE UNSPECIFIED
CTS53846Medicare UPIN