Healthcare Provider Details

I. General information

NPI: 1518175173
Provider Name (Legal Business Name): MELISSA SUSAN HENRETTA MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

231 WESTMONT ST
WEST HARTFORD CT
06117-2935
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4000
  • Fax:
Mailing address:
  • Phone: 614-203-1348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number261553
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number56675
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: