Healthcare Provider Details

I. General information

NPI: 1407880487
Provider Name (Legal Business Name): MARY JULIA MARTIN-O'BRIEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

IV. Provider business mailing address

555 WILLARD AVE
NEWINGTON CT
06111-2631
US

V. Phone/Fax

Practice location:
  • Phone: 860-666-6951
  • Fax: 860-667-6738
Mailing address:
  • Phone: 860-666-6951
  • Fax: 860-667-6738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number001456
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: