Healthcare Provider Details

I. General information

NPI: 1700678844
Provider Name (Legal Business Name): NEZHA ELOMARI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WATERVILLE RD
AVON CT
06001-2097
US

IV. Provider business mailing address

21 WATERVILLE RD
AVON CT
06001-2097
US

V. Phone/Fax

Practice location:
  • Phone: 860-284-0182
  • Fax: 860-284-6804
Mailing address:
  • Phone: 860-284-0182
  • Fax: 860-284-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number014317
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: