Healthcare Provider Details

I. General information

NPI: 1962002691
Provider Name (Legal Business Name): MARIELLE HELLERUD KHUEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 FIFTH ST
NORWALK CT
06855-2402
US

IV. Provider business mailing address

39 FIFTH ST
NORWALK CT
06855-2402
US

V. Phone/Fax

Practice location:
  • Phone: 178-145-4677
  • Fax:
Mailing address:
  • Phone: 178-145-4677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020090994
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: