Healthcare Provider Details

I. General information

NPI: 1093552531
Provider Name (Legal Business Name): IZABELLA PALAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 08/15/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 N FRONTAGE RD
NEW LONDON CT
06320-2628
US

IV. Provider business mailing address

1290 SILAS DEANE HIGHWAY HHC - CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-865-0934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13495
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: