Healthcare Provider Details

I. General information

NPI: 1396705216
Provider Name (Legal Business Name): THERESA GWOZDZ APRN, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FOUNDERS PLZ #300 C/O IPMS
EAST HARTFORD CT
06108-3212
US

IV. Provider business mailing address

111 FOUNDERS PLZ #300 C/O IPMS
EAST HARTFORD CT
06108-3212
US

V. Phone/Fax

Practice location:
  • Phone: 860-282-4137
  • Fax: 860-282-0170
Mailing address:
  • Phone: 860-282-4137
  • Fax: 860-282-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number000349
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: