Provider Demographics
NPI:1700125804
Name:RODRIGUEZ, MARISOL (APRN)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 HAMPTON CT
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-1144
Mailing Address - Country:US
Mailing Address - Phone:860-983-9965
Mailing Address - Fax:
Practice Address - Street 1:127 HAMPTON CT
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-1144
Practice Address - Country:US
Practice Address - Phone:860-983-9965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-08
Last Update Date:2021-03-30
Deactivation Date:2020-11-30
Deactivation Code:
Reactivation Date:2021-01-13
Provider Licenses
StateLicense IDTaxonomies
CT03-464286173C00000X
CT9362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT03-464286OtherMASSAGE THERAPIST STATE LICENSE