Healthcare Provider Details

I. General information

NPI: 1831769082
Provider Name (Legal Business Name): AVITAL GREENER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06106-3315
US

IV. Provider business mailing address

299 MILE CREEK RD
OLD LYME CT
06371-1815
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-5000
  • Fax:
Mailing address:
  • Phone: 860-373-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number9875
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: