Healthcare Provider Details

I. General information

NPI: 1578503934
Provider Name (Legal Business Name): MARY ANNE LAVIN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CHAPEL ST
NEW HAVEN CT
06511-4405
US

IV. Provider business mailing address

103 OXBOW LN
GUILFORD CT
06437-2054
US

V. Phone/Fax

Practice location:
  • Phone: 203-789-3661
  • Fax: 203-789-4037
Mailing address:
  • Phone: 203-453-6058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number000729
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: