Healthcare Provider Details

I. General information

NPI: 1720194939
Provider Name (Legal Business Name): ANNA HAZEL GODDARD APRN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA HAZEL TIELSCH-GODDARD APRN, CPNP-PC

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 VAUXHALL ST CHILD & FAMILY AGENCY OF SECT, INC.
NEW LONDON CT
06320-5711
US

IV. Provider business mailing address

255 HEMPSTEAD ST
NEW LONDON CT
06320-6204
US

V. Phone/Fax

Practice location:
  • Phone: 860-442-2797
  • Fax: 860-701-3776
Mailing address:
  • Phone: 860-443-2896
  • Fax: 860-442-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number765853
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number3291
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number73362
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: