Healthcare Provider Details

I. General information

NPI: 1104745884
Provider Name (Legal Business Name): NATHANIEL RAINES APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 MIX AVE
HAMDEN CT
06514-2102
US

IV. Provider business mailing address

45 WOODIN ST
HAMDEN CT
06514-4403
US

V. Phone/Fax

Practice location:
  • Phone: 203-281-3500
  • Fax:
Mailing address:
  • Phone: 203-464-7915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number17885
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: