Healthcare Provider Details

I. General information

NPI: 1275451502
Provider Name (Legal Business Name): FARA PHILIDOR APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHAWS CV
NEW LONDON CT
06320-4902
US

IV. Provider business mailing address

19 GRAND ST
MIDDLETOWN CT
06457-2705
US

V. Phone/Fax

Practice location:
  • Phone: 860-447-8304
  • Fax: 860-443-8720
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-343-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number17840
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: