Healthcare Provider Details

I. General information

NPI: 1265275531
Provider Name (Legal Business Name): BRENDA CASTILLO JIMINIAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ALBANY AVE
HARTFORD CT
06120-2508
US

IV. Provider business mailing address

500 ALBANY AVE
HARTFORD CT
06120-2508
US

V. Phone/Fax

Practice location:
  • Phone: 860-249-9625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number13419
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: