Provider Demographics
NPI:1821119843
Name:TAGAN CONROY, WENDY ANN (APRN)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ANN
Last Name:TAGAN CONROY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-6748
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1859
Practice Address - Country:US
Practice Address - Phone:860-342-3392
Practice Address - Fax:860-358-8658
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008038721Medicaid
CT008038721Medicaid
Q47138Medicare UPIN