Healthcare Provider Details

I. General information

NPI: 1114115706
Provider Name (Legal Business Name): PRACTITIONER SUPPORT SERVICES LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 ELM ST STE 202B
MONROE CT
06468-2284
US

IV. Provider business mailing address

PO BOX 4058
MONROE CT
06468-9998
US

V. Phone/Fax

Practice location:
  • Phone: 203-518-2124
  • Fax:
Mailing address:
  • Phone: 203-518-2124
  • Fax: 888-496-0267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID V PENRY
Title or Position: PRESIDENT
Credential: NP-C
Phone: 203-518-2124