Healthcare Provider Details

I. General information

NPI: 1356790752
Provider Name (Legal Business Name): MANDI L BOISVERT FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON STREET
HARTFORD CT
06106
US

IV. Provider business mailing address

188 IMPERIAL DRIVE
GLASTONBURY CT
06033
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9200
  • Fax: 860-545-9134
Mailing address:
  • Phone: 860-986-4739
  • Fax: 860-430-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6546
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: