Healthcare Provider Details

I. General information

NPI: 1659354827
Provider Name (Legal Business Name): MARIA BANEVICIUS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 MIDDLE TPKE W
MANCHESTER CT
06040-3833
US

IV. Provider business mailing address

345 WHITNEY AVE
NEW HAVEN CT
06511-2348
US

V. Phone/Fax

Practice location:
  • Phone: 860-643-1607
  • Fax: 203-752-8785
Mailing address:
  • Phone: 203-752-2856
  • Fax: 203-752-8785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number000714
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: