Healthcare Provider Details

I. General information

NPI: 1295341477
Provider Name (Legal Business Name): PAULA ANDREA HERNANDEZ ORTIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2020
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

863 N MAIN STREET EXT STE 200
WALLINGFORD CT
06492-2434
US

IV. Provider business mailing address

863 N MAIN STREET EXT STE 200
WALLINGFORD CT
06492-2434
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-3280
  • Fax: 203-741-6569
Mailing address:
  • Phone: 203-265-3280
  • Fax: 203-741-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12795
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: