Healthcare Provider Details

I. General information

NPI: 1447226915
Provider Name (Legal Business Name): DIANE ROSE CROLL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BOND ST
BRIDGEPORT CT
06610-2205
US

IV. Provider business mailing address

9 OAKLAND DR
TRUMBULL CT
06611-1909
US

V. Phone/Fax

Practice location:
  • Phone: 203-384-6505
  • Fax:
Mailing address:
  • Phone: 203-459-2495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002827
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2827
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: