Healthcare Provider Details

I. General information

NPI: 1659963155
Provider Name (Legal Business Name): CARRIE ANN WALDRON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 WESTCOTT RD
DANIELSON CT
06239-2929
US

IV. Provider business mailing address

829 STAFFORD RD
STORRS CT
06268-2006
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-9540
  • Fax:
Mailing address:
  • Phone: 860-840-9486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9382
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9382
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: