Healthcare Provider Details

I. General information

NPI: 1871676544
Provider Name (Legal Business Name): TARA L HODGKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

547 ADDISON RD
GLASTONBURY CT
06033-1302
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-6654
  • Fax:
Mailing address:
  • Phone: 860-888-8134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number068992
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: