Healthcare Provider Details

I. General information

NPI: 1518979855
Provider Name (Legal Business Name): AMY LOUISE SMITH- BASSETT APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 PARK RD STE 2
WEST HARTFORD CT
06119-1898
US

IV. Provider business mailing address

315 E CENTER ST
MANCHESTER CT
06040-5251
US

V. Phone/Fax

Practice location:
  • Phone: 860-533-0179
  • Fax:
Mailing address:
  • Phone: 860-533-0179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041299719
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209004736
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number000333
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: