Healthcare Provider Details

I. General information

NPI: 1043892094
Provider Name (Legal Business Name): LAURA MANDELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 TAMARACK AVE
SOUTH WINDSOR CT
06074-5562
US

IV. Provider business mailing address

2701 TAMARACK AVE
SOUTH WINDSOR CT
06074-5562
US

V. Phone/Fax

Practice location:
  • Phone: 508-259-6656
  • Fax:
Mailing address:
  • Phone: 860-647-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number9678
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number134948
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number134948
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: