Healthcare Provider Details

I. General information

NPI: 1861107591
Provider Name (Legal Business Name): KERISHA S PRINCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 07/31/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 FARMINGTON AVE
WEST HARTFORD CT
06107-2105
US

IV. Provider business mailing address

92 CHENEY LN
EAST HARTFORD CT
06118-3005
US

V. Phone/Fax

Practice location:
  • Phone: 860-521-8035
  • Fax: 860-521-8036
Mailing address:
  • Phone: 718-501-9840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number011413
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number153956
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: