Provider Demographics
NPI:1649352790
Name:RICHARD, MARILYN ANDERSEN (APRN)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:ANDERSEN
Last Name:RICHARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 COLONEL LEDYARD HWY
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-1909
Mailing Address - Country:US
Mailing Address - Phone:860-572-7556
Mailing Address - Fax:860-572-2976
Practice Address - Street 1:333 COLONEL LEDYARD HWY
Practice Address - Street 2:
Practice Address - City:LEDYARD
Practice Address - State:CT
Practice Address - Zip Code:06339-1909
Practice Address - Country:US
Practice Address - Phone:860-572-7556
Practice Address - Fax:860-572-2976
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000795363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002771294Medicaid
CT890000037Medicare UPIN