Healthcare Provider Details

I. General information

NPI: 1740507847
Provider Name (Legal Business Name): STACY ANN DATRE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PERRYRIDGE RD
GREENWICH CT
06830-4608
US

IV. Provider business mailing address

110 COLONY RD
SEYMOUR CT
06483-3252
US

V. Phone/Fax

Practice location:
  • Phone: 203-863-3553
  • Fax:
Mailing address:
  • Phone: 203-732-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberE54875
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: