Provider Demographics
NPI:1912909524
Name:LEVINE, EILEEN POND (APRN)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:POND
Last Name:LEVINE
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 1:455 CHASE PKWY FL 3
Mailing Address - Street 2:WATERBURY HOSPITAL
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3352
Mailing Address - Country:US
Mailing Address - Phone:203-578-3940
Mailing Address - Fax:203-573-1527
Practice Address - Street 1:455 CHASE PKWY FL 3
Practice Address - Street 2:WATERBURY HOSPITAL
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3352
Practice Address - Country:US
Practice Address - Phone:203-578-3940
Practice Address - Fax:203-573-1527
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002617363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004242963Medicaid
CT004242963Medicaid
CTQ14506Medicare UPIN