Healthcare Provider Details

I. General information

NPI: 1073552865
Provider Name (Legal Business Name): DIANE M BRAY APRN, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

664 PROSPECT AVE
HARTFORD CT
06105-4203
US

IV. Provider business mailing address

554 NILES RD
NEW HARTFORD CT
06057-2412
US

V. Phone/Fax

Practice location:
  • Phone: 860-236-8087
  • Fax: 860-586-7422
Mailing address:
  • Phone: 860-379-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number000772
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: