Provider Demographics
NPI:1780024943
Name:PRATT, IDA R (CHW)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:R
Last Name:PRATT
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 PUTNAM AVE UNIT 6535
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-7722
Mailing Address - Country:US
Mailing Address - Phone:475-301-8414
Mailing Address - Fax:203-745-4595
Practice Address - Street 1:1000 LAFAYETTE BLVD STE 1100
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4710
Practice Address - Country:US
Practice Address - Phone:475-301-8414
Practice Address - Fax:203-745-4595
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNA198508376K00000X
CT19793616172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's Aide