Healthcare Provider Details

I. General information

NPI: 1255309225
Provider Name (Legal Business Name): ROBERTA M BORDEN CRNA MS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 MAIN ST
MANCHESTER CT
06040-6014
US

IV. Provider business mailing address

80 STAPLES LN
GLASTONBURY CT
06033-3924
US

V. Phone/Fax

Practice location:
  • Phone: 860-649-1550
  • Fax: 860-649-1091
Mailing address:
  • Phone: 860-657-8598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number036612
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: