Healthcare Provider Details

I. General information

NPI: 1720761091
Provider Name (Legal Business Name): AMANDA NICOLE ZARATE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOHEGAN AVE
NEW LONDON CT
06320-8110
US

IV. Provider business mailing address

45 MOHEGAN AVE
NEW LONDON CT
06320-8110
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-1015
  • Fax:
Mailing address:
  • Phone: 860-442-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: