Healthcare Provider Details

I. General information

NPI: 1811157431
Provider Name (Legal Business Name): WAZIDA TABASSUM DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 SOUTH RD STE LL-10
FARMINGTON CT
06032-2483
US

IV. Provider business mailing address

345 BUCKLAND HILLS DR APT 11232
MANCHESTER CT
06042-8704
US

V. Phone/Fax

Practice location:
  • Phone: 860-404-2189
  • Fax: 860-404-2213
Mailing address:
  • Phone: 203-209-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number001764
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18344
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: