Provider Demographics
NPI:1952633703
Name:AGOSTINELLI, BLANCHE C (APRN)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:C
Last Name:AGOSTINELLI
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 1:67 MASONIC AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3095
Mailing Address - Country:US
Mailing Address - Phone:203-265-5720
Mailing Address - Fax:203-679-5623
Practice Address - Street 1:67 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3095
Practice Address - Country:US
Practice Address - Phone:203-265-5720
Practice Address - Fax:203-679-5623
Is Sole Proprietor?:No
Enumeration Date:2010-02-04
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000960364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult