Healthcare Provider Details

I. General information

NPI: 1518976885
Provider Name (Legal Business Name): MARY ELIZABETH NICHOLS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 FRANKLIN ST
WATERBURY CT
06706-1221
US

IV. Provider business mailing address

99 EAST RIVER DRIVE 5TH FLOOR
EAST HARTFORD CT
06108
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-6196
  • Fax:
Mailing address:
  • Phone: 860-282-0833
  • Fax: 860-571-9260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number000004
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: