Healthcare Provider Details

I. General information

NPI: 1396578159
Provider Name (Legal Business Name): AMANDA HEALEY ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

IV. Provider business mailing address

27 HEBRON LDG
HEBRON CT
06248-1335
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number12.013743
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10.155566
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: