Healthcare Provider Details

I. General information

NPI: 1659627669
Provider Name (Legal Business Name): MARINA JEAN SYRAX APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR STREET HARTFORD HOSPITAL SURGERY DEPT
HARTFORD CT
06102-5037
US

IV. Provider business mailing address

PO BOX 415933 HARTFORD HOSPITAL PROFESSIONAL SERVICES
BOSTON MA
02241-5933
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-4670
  • Fax:
Mailing address:
  • Phone: 860-545-7602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number005716
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number005716
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License NumberRN1027251
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: