Healthcare Provider Details

I. General information

NPI: 1932940863
Provider Name (Legal Business Name): ANA FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

IV. Provider business mailing address

40 MANSFIELD AVE
WILLIMANTIC CT
06226-2018
US

V. Phone/Fax

Practice location:
  • Phone: 860-450-7471
  • Fax:
Mailing address:
  • Phone: 860-450-7471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13360
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number189944
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: