Provider Demographics
NPI:1720399793
Name:CONNERTON, GINA M (MLP-NP)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:M
Last Name:CONNERTON
Suffix:
Gender:F
Credentials:MLP-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DUDLEY AVE S
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5421
Mailing Address - Country:US
Mailing Address - Phone:401-847-5501
Mailing Address - Fax:
Practice Address - Street 1:101 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2401
Practice Address - Country:US
Practice Address - Phone:401-274-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI20010098363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal