MEDICARE: JULIO A ENRIQUEZ ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AC003804	MD
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	105902	WV

General Provider Information

NPI Number	:	1689981904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIO A ENRIQUEZ ARNP

Provider Business Mailing Address
First Line	:	PO BOX 1595
Second Line	:
City	:	MIDDLETOWN
State	:	CT
Zip	:	06457-8095
Country	:	US
Telephone Number	:	860-788-6404
Fax Number	:

Provider Business Practice Location Address
First Line	:	5400 BIG TYLER RD # D
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25313-1178
Country	:	US
Telephone Number	:	860-788-6404
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2010
Last Update Date	:	06/18/2024

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