Healthcare Provider Details

I. General information

NPI: 1063754406
Provider Name (Legal Business Name): JANELLE C FERN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 BROCKETT ST
NEWINGTON CT
06111-3907
US

IV. Provider business mailing address

262 BROCKETT ST
NEWINGTON CT
06111-3907
US

V. Phone/Fax

Practice location:
  • Phone: 860-667-2020
  • Fax: 860-667-0770
Mailing address:
  • Phone: 860-667-2020
  • Fax: 860-667-0770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2888
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: