Healthcare Provider Details

I. General information

NPI: 1700023603
Provider Name (Legal Business Name): MARYBETH REILEY NORMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARYBETH REILEY

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 COTTAGE GROVE RD SUITE 205
BLOOMFIELD CT
06002-3088
US

IV. Provider business mailing address

1000 ASYLUM AVE SUITE 2109A
HARTFORD CT
06105-1770
US

V. Phone/Fax

Practice location:
  • Phone: 860-286-2996
  • Fax: 860-286-0862
Mailing address:
  • Phone: 860-714-6581
  • Fax: 860-714-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number004031
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number004031
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: