Healthcare Provider Details

I. General information

NPI: 1689307381
Provider Name (Legal Business Name): TRICIA VARHOLAK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 ALBANY TPKE STE 101
CANTON CT
06019-2507
US

IV. Provider business mailing address

PO BOX 379
COLCHESTER CT
06415-0379
US

V. Phone/Fax

Practice location:
  • Phone: 860-658-3444
  • Fax:
Mailing address:
  • Phone: 860-490-8698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberE58145
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10685
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: