Healthcare Provider Details

I. General information

NPI: 1730536293
Provider Name (Legal Business Name): SANDRA LYNN DIMARIO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2016
Last Update Date: 05/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 HARTFORD RD
MANCHESTER CT
06040-5972
US

IV. Provider business mailing address

151 HARTFORD RD
MANCHESTER CT
06040-5972
US

V. Phone/Fax

Practice location:
  • Phone: 860-643-1076
  • Fax: 860-647-1101
Mailing address:
  • Phone: 860-643-1076
  • Fax: 860-647-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberR43581
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: