Provider Demographics
NPI:1184334633
Name:ETIM, ITORO JOSEPH
Entity type:Individual
Prefix:MISS
First Name:ITORO
Middle Name:JOSEPH
Last Name:ETIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3268
Mailing Address - Country:US
Mailing Address - Phone:860-508-8587
Mailing Address - Fax:
Practice Address - Street 1:816 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-4350
Practice Address - Country:US
Practice Address - Phone:203-238-1125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-23
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11263363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner