Healthcare Provider Details

I. General information

NPI: 1669712188
Provider Name (Legal Business Name): ROLAND ADDO NUBUOR CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2013
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberRN2261441
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2261441
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: