Healthcare Provider Details

I. General information

NPI: 1881713345
Provider Name (Legal Business Name): CHARLES F WETMORE APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 PECK ST
NORTH HAVEN CT
06473-2308
US

IV. Provider business mailing address

13 PECK ST
NORTH HAVEN CT
06473-2308
US

V. Phone/Fax

Practice location:
  • Phone: 203-239-4627
  • Fax: 203-234-8533
Mailing address:
  • Phone: 203-239-4627
  • Fax: 203-234-8533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number002351
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: