Healthcare Provider Details

I. General information

NPI: 1982272084
Provider Name (Legal Business Name): REENA MATHEW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 201
NORWALK CT
06851-1080
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HARTFORD HEALTHCARE-CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 203-838-4000
  • Fax: 203-845-9535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10226
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number74106
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number74106
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: