Healthcare Provider Details

I. General information

NPI: 1649352790
Provider Name (Legal Business Name): MARILYN ANDERSEN RICHARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COLONEL LEDYARD HWY
LEDYARD CT
06339-1909
US

IV. Provider business mailing address

333 COLONEL LEDYARD HWY
LEDYARD CT
06339-1909
US

V. Phone/Fax

Practice location:
  • Phone: 860-572-7556
  • Fax: 860-572-2976
Mailing address:
  • Phone: 860-572-7556
  • Fax: 860-572-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number000795
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: