Provider Demographics
NPI:1700023603
Name:NORMAN, MARYBETH REILEY (APRN)
Entity Type:Individual
Prefix:
First Name:MARYBETH
Middle Name:REILEY
Last Name:NORMAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARYBETH
Other - Middle Name:
Other - Last Name:REILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:580 COTTAGE GROVE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-3088
Practice Address - Country:US
Practice Address - Phone:860-286-2996
Practice Address - Fax:860-286-0862
Is Sole Proprietor?:No
Enumeration Date:2009-01-14
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004031363LX0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology