Provider Demographics
NPI:1912296419
Name:OUELLETTE, JENNIFER ELIZABETH (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:ELMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:170 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2525
Mailing Address - Country:US
Mailing Address - Phone:203-759-3666
Mailing Address - Fax:203-759-3671
Practice Address - Street 1:170 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2525
Practice Address - Country:US
Practice Address - Phone:203-759-3666
Practice Address - Fax:203-759-3671
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004621363LF0000X
CT4621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235976Medicaid
CT008031012Medicaid
CT008031012Medicaid