Healthcare Provider Details

I. General information

NPI: 1275143778
Provider Name (Legal Business Name): MARYAM ABDISHOO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 KENNEDY DR
PUTNAM CT
06260-1939
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-6541
  • Fax:
Mailing address:
  • Phone: 860-928-6541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11977
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: