Healthcare Provider Details

I. General information

NPI: 1164868030
Provider Name (Legal Business Name): MARY SCHULTZ FORMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY S FORMAN

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MAIN ST
WEST HAVEN CT
06516-4296
US

IV. Provider business mailing address

661 EAST ST
LITCHFIELD CT
06759-3721
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-1184
  • Fax: 203-931-0063
Mailing address:
  • Phone: 860-733-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number004082
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: