Healthcare Provider Details

I. General information

NPI: 1033692819
Provider Name (Legal Business Name): MICHELLE S KODUAH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2018
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CAPITAL BLVD
ROCKY HILL CT
06067-3576
US

IV. Provider business mailing address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

V. Phone/Fax

Practice location:
  • Phone: 860-221-0791
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7896
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number119083
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: