Healthcare Provider Details

I. General information

NPI: 1629721402
Provider Name (Legal Business Name): BARTHOLOMEW J VAZQUEZ FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

IV. Provider business mailing address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

V. Phone/Fax

Practice location:
  • Phone: 541-281-2223
  • Fax:
Mailing address:
  • Phone: 541-281-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10341
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: