Healthcare Provider Details

I. General information

NPI: 1407591894
Provider Name (Legal Business Name): TESS MARIE CAGENELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2022
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 CEDAR RD
MYSTIC CT
06355-2163
US

IV. Provider business mailing address

97 CEDAR RD
MYSTIC CT
06355-2163
US

V. Phone/Fax

Practice location:
  • Phone: 860-951-5723
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number146028
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN03281
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: