Healthcare Provider Details

I. General information

NPI: 1255307823
Provider Name (Legal Business Name): MICHELLE A CRETELLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 BOSTON POST RD
EAST LYME CT
06333-1605
US

IV. Provider business mailing address

20 ANDERSEN CT
WESTERLY RI
02891-3712
US

V. Phone/Fax

Practice location:
  • Phone: 860-739-0348
  • Fax: 860-739-6779
Mailing address:
  • Phone: 401-539-2461
  • Fax: 401-539-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD10078
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number49231
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: