Healthcare Provider Details

I. General information

NPI: 1346424710
Provider Name (Legal Business Name): ELIZABETH MARSHALL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WILDWOOD MEDICAL CTR
ESSEX CT
06426-1155
US

IV. Provider business mailing address

1 WILDWOOD MEDICAL CTR
ESSEX CT
06426-1155
US

V. Phone/Fax

Practice location:
  • Phone: 860-767-0168
  • Fax:
Mailing address:
  • Phone: 860-767-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number7214
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number075893-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: