Healthcare Provider Details

I. General information

NPI: 1144501800
Provider Name (Legal Business Name): ALICE GANCSOS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 04/09/2019
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

65 DWIGHT ST #55
NEW HAVEN CT
06511-5358
US

V. Phone/Fax

Practice location:
  • Phone: 203-880-5335
  • Fax:
Mailing address:
  • Phone: 617-913-3610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4787
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: