Healthcare Provider Details

I. General information

NPI: 1982192209
Provider Name (Legal Business Name): TARANNUM MALWAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 01/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 CROMWELL AVE
ROCKY HILL CT
06067
US

IV. Provider business mailing address

39 BUCKLAND ST APT 1112-4
MANCHESTER CT
06042-7721
US

V. Phone/Fax

Practice location:
  • Phone: 860-372-4990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7488
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: