Healthcare Provider Details

I. General information

NPI: 1588462303
Provider Name (Legal Business Name): MYLENE GERONIMO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 THOMAS WAITE DR
OLD LYME CT
06371-1546
US

IV. Provider business mailing address

8 THOMAS WAITE DR
OLD LYME CT
06371-1546
US

V. Phone/Fax

Practice location:
  • Phone: 860-514-5286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number17034
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: