Healthcare Provider Details

I. General information

NPI: 1730636408
Provider Name (Legal Business Name): CARINA HOLMGREN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 POMFRET ST
PUTNAM CT
06260-1833
US

IV. Provider business mailing address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-963-7917
  • Fax: 860-963-0015
Mailing address:
  • Phone: 860-450-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6726
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: