Provider Demographics
NPI:1396081162
Name:JOSEPH, MARIE CAROLLE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:CAROLLE
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:80 HOOKER RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-1316
Mailing Address - Country:US
Mailing Address - Phone:203-345-3095
Mailing Address - Fax:
Practice Address - Street 1:949 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3142
Practice Address - Country:US
Practice Address - Phone:203-878-6365
Practice Address - Fax:203-301-2397
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005094363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1396081162Medicaid