Healthcare Provider Details

I. General information

NPI: 1184537516
Provider Name (Legal Business Name): MATTHEW LETTICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3202
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3202
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-4748
  • Fax: 203-688-4740
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number256470
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17639
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: