Healthcare Provider Details

I. General information

NPI: 1760623185
Provider Name (Legal Business Name): TAMIKQUE VANE ESCOURSE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2009
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 W MAIN ST
AVON CT
06001-4357
US

IV. Provider business mailing address

355 CAPTAIN THOMAS BLVD UNIT 52
WEST HAVEN CT
06516-5802
US

V. Phone/Fax

Practice location:
  • Phone: 860-212-5040
  • Fax: 860-545-3755
Mailing address:
  • Phone: 929-240-0985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33335747
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: