Healthcare Provider Details

I. General information

NPI: 1790394518
Provider Name (Legal Business Name): JENNA DELUCIA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA HERNANDEZ APRN

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 MAIN AVE STE 106
NORWALK CT
06851-1080
US

IV. Provider business mailing address

761 MAIN AVE STE 106
NORWALK CT
06851-1080
US

V. Phone/Fax

Practice location:
  • Phone: 203-846-8885
  • Fax: 203-846-6032
Mailing address:
  • Phone: 203-846-8885
  • Fax: 203-846-6032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number9033
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number164932
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: