MEDICARE: KHUSHBOO SURTI APRN, PMHNP-BC

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	9177	CT

General Provider Information

NPI Number	:	1942815782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHUSHBOO SURTI APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:	860-432-7771
Fax Number	:	860-432-7774

Provider Business Practice Location Address
First Line	:	925 SULLIVAN AVE STE 2
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-2080
Country	:	US
Telephone Number	:	860-432-7771
Fax Number	:	860-432-7774

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

Provider Enumeration Date	:	09/09/2020
Last Update Date	:	05/04/2023

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