Healthcare Provider Details

I. General information

NPI: 1083317390
Provider Name (Legal Business Name): REGENERISE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 10/20/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHURCH ST
WALLINGFORD CT
06492-2253
US

IV. Provider business mailing address

300 CHURCH ST STE 103
WALLINGFORD CT
06492-2253
US

V. Phone/Fax

Practice location:
  • Phone: 860-994-7339
  • Fax:
Mailing address:
  • Phone: 860-994-7339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AUTHURINE HANNAM-DAVIS
Title or Position: FAMILY NURSE PRACTITIONER
Credential: NP
Phone: 860-994-7339