Healthcare Provider Details

I. General information

NPI: 1760846042
Provider Name (Legal Business Name): LAWRENCE OGBOGU APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1279 W MAIN ST
WATERBURY CT
06708-3101
US

IV. Provider business mailing address

19 OLD SCHOOLHOUSE RD
PROSPECT CT
06712-1210
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-5490
  • Fax:
Mailing address:
  • Phone: 203-543-2873
  • Fax: 203-919-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.006518
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12.006518
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6518
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: