Provider Demographics
NPI:1891338398
Name:MATHEW, NEETHU (APRN FNP-BC)
Entity Type:Individual
Prefix:
First Name:NEETHU
Middle Name:
Last Name:MATHEW
Suffix:
Gender:F
Credentials:APRN FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4360
Mailing Address - Country:US
Mailing Address - Phone:860-992-2924
Mailing Address - Fax:
Practice Address - Street 1:845 PADDOCK AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7021
Practice Address - Country:US
Practice Address - Phone:203-238-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104565163W00000X
CT12.008572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse