Healthcare Provider Details

I. General information

NPI: 1972165728
Provider Name (Legal Business Name): GINA V LANG FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 BOSTON POST RD STE 105
MADISON CT
06443-3476
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-5100
  • Fax: 860-358-8655
Mailing address:
  • Phone: 860-358-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number013321
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: