Provider Demographics
NPI:1295441772
Name:BERMEO, MARIANA
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:BERMEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIANA
Other - Middle Name:
Other - Last Name:LATIU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3859
Mailing Address - Country:US
Mailing Address - Phone:203-528-3455
Mailing Address - Fax:
Practice Address - Street 1:30 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3859
Practice Address - Country:US
Practice Address - Phone:203-528-3455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-27
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT012367363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily