Healthcare Provider Details

I. General information

NPI: 1366050411
Provider Name (Legal Business Name): CASEY AIVANO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITAIN CT
06052-2016
US

IV. Provider business mailing address

145 WHISTLING STRAITS DR
SOUTHINGTON CT
06489-1189
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5011
  • Fax:
Mailing address:
  • Phone: 860-729-7044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9038
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: