Healthcare Provider Details

I. General information

NPI: 1154317147
Provider Name (Legal Business Name): MONICA JUNE CHACLAS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 HAWLEY LN
TRUMBULL CT
06611-5300
US

IV. Provider business mailing address

471 OLD POVERTY RD
SOUTHBURY CT
06488-1760
US

V. Phone/Fax

Practice location:
  • Phone: 203-375-3456
  • Fax:
Mailing address:
  • Phone: 203-267-7703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number001434
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: