Healthcare Provider Details

I. General information

NPI: 1548500663
Provider Name (Legal Business Name): MARZENA GRYCZEWSKI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE # 506
NEWINGTON CT
06111-2631
US

IV. Provider business mailing address

555 WILLARD AVE # 506
NEWINGTON CT
06111-2631
US

V. Phone/Fax

Practice location:
  • Phone: 860-256-1553
  • Fax: 860-667-6799
Mailing address:
  • Phone: 860-256-1553
  • Fax: 860-667-6799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number004919
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number004919
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: