Healthcare Provider Details

I. General information

NPI: 1407318637
Provider Name (Legal Business Name): DOMENICK BIANCHI APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 04/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CHESTNUT HILL RD
STAFFORD SPRINGS CT
06076-4005
US

IV. Provider business mailing address

103 STAFFORD ST
STAFFORD SPRINGS CT
06076-4336
US

V. Phone/Fax

Practice location:
  • Phone: 413-455-6638
  • Fax:
Mailing address:
  • Phone: 413-455-6638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number8139
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: