Provider Demographics
NPI:1710605845
Name:PROFESSIONAL NURSE PRACTITIONER
Entity Type:Organization
Organization Name:PROFESSIONAL NURSE PRACTITIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISOL
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:475-302-6667
Mailing Address - Street 1:127 HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1144
Mailing Address - Country:US
Mailing Address - Phone:860-983-9965
Mailing Address - Fax:
Practice Address - Street 1:127 HAMPTON CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1144
Practice Address - Country:US
Practice Address - Phone:860-983-9965
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty