Healthcare Provider Details

I. General information

NPI: 1265785299
Provider Name (Legal Business Name): ABBY ANN GLORIA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 REYNOLDS ST
DANIELSON CT
06239-2917
US

IV. Provider business mailing address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-7501
  • Fax: 860-779-2191
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005182
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: