Healthcare Provider Details

I. General information

NPI: 1386263010
Provider Name (Legal Business Name): MARY KATHERINE MORRISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 08/21/2022
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 LONG WHARF DR STE 302
NEW HAVEN CT
06511-5593
US

IV. Provider business mailing address

11 FOX HOLLOW RD
OLD SAYBROOK CT
06475-1077
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5178
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: