Healthcare Provider Details

I. General information

NPI: 1174643530
Provider Name (Legal Business Name): MARYELLEN PACHLER PACHLER KENNELL A.P.R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARYELLEN CREAMER PACHLER A.P.R.N.

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 EAST PUTNAM AVE. 2ND FLOOR SUITE #1
COS COB CT
06807
US

IV. Provider business mailing address

399 EAST PUTNAM AVE. 2ND FLOOR SUITE #1
COS COB CT
06807
US

V. Phone/Fax

Practice location:
  • Phone: 860-478-4134
  • Fax: 203-769-1366
Mailing address:
  • Phone: 860-478-4134
  • Fax: 203-769-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCTAPRN003159
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number003159
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number003159
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: