Healthcare Provider Details

I. General information

NPI: 1629475371
Provider Name (Legal Business Name): WINDHAM COMMUNITY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

IV. Provider business mailing address

PO BOX 4131
YALESVILLE CT
06492-1481
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-6752
  • Fax: 203-265-4557
Mailing address:
  • Phone: 203-284-1340
  • Fax: 203-265-4557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JANICE M MACKIE
Title or Position: FINANCIAL OFFICER
Credential:
Phone: 860-425-8755