Healthcare Provider Details

I. General information

NPI: 1881661817
Provider Name (Legal Business Name): MANON GUIDA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 HEBRON AVE SUITE 107
GLASTONBURY CT
06033-2421
US

IV. Provider business mailing address

622 HEBRON AVE SUITE 107
GLASTONBURY CT
06033-2421
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-3376
  • Fax: 860-633-7712
Mailing address:
  • Phone: 860-657-3376
  • Fax: 860-633-7712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WU0100X
TaxonomyUrology Registered Nurse
License Number002062
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number002062
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: