Healthcare Provider Details

I. General information

NPI: 1952633703
Provider Name (Legal Business Name): BLANCHE C. AGOSTINELLI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 MASONIC AVE
WALLINGFORD CT
06492-3095
US

IV. Provider business mailing address

67 MASONIC AVE
WALLINGFORD CT
06492-3095
US

V. Phone/Fax

Practice location:
  • Phone: 203-265-5720
  • Fax: 203-679-5623
Mailing address:
  • Phone: 203-265-5720
  • Fax: 203-679-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number000960
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: