Healthcare Provider Details

I. General information

NPI: 1104442771
Provider Name (Legal Business Name): ARIYE M KRASSNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
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 Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12.008902
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: