Provider Demographics
NPI:1700187192
Name:RICHARD, AMELITA L (APRN)
Entity Type:Individual
Prefix:MRS
First Name:AMELITA
Middle Name:L
Last Name:RICHARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:2800 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4201
Mailing Address - Country:US
Mailing Address - Phone:203-576-5791
Mailing Address - Fax:203-576-5022
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-576-5791
Practice Address - Fax:203-576-5022
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004339363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health