Healthcare Provider Details

I. General information

NPI: 1093573776
Provider Name (Legal Business Name): TERESA PUCKHABER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 S MAIN ST
CHESHIRE CT
06410-3111
US

IV. Provider business mailing address

114 S MAIN ST
CHESHIRE CT
06410-3111
US

V. Phone/Fax

Practice location:
  • Phone: 860-485-7573
  • Fax:
Mailing address:
  • Phone: 860-485-7573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6547
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number6547
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number6547
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: