Healthcare Provider Details

I. General information

NPI: 1710234448
Provider Name (Legal Business Name): AERICKA ROBYN KHONGDY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 WESTERN BLVD STE 104
GLASTONBURY CT
06033-1276
US

IV. Provider business mailing address

120 WEBSTER SQUARE RD
BERLIN CT
06037-2329
US

V. Phone/Fax

Practice location:
  • Phone: 860-657-5940
  • Fax:
Mailing address:
  • Phone: 860-829-0707
  • Fax: 860-829-0606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number005063
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number005063
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: