Healthcare Provider Details

I. General information

NPI: 1689805749
Provider Name (Legal Business Name): DIANA VITA GOVOLA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA VITA JIN APRN

II. Dates (important events)

Enumeration Date: 08/06/2009
Last Update Date: 06/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CAPITAL BLVD 3RD FLOOR
ROCKY HILL CT
06067-3576
US

IV. Provider business mailing address

400 CAPITAL BLVD 3RD FLOOR
ROCKY HILL CT
06067-3576
US

V. Phone/Fax

Practice location:
  • Phone: 860-560-6979
  • Fax: 860-702-9446
Mailing address:
  • Phone: 860-560-6979
  • Fax: 860-702-9446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4143
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: