Healthcare Provider Details

I. General information

NPI: 1770192320
Provider Name (Legal Business Name): TINA VARUGHESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 S BRADFORD ST
DOVER DE
19904-4137
US

IV. Provider business mailing address

807 S BRADFORD ST
DOVER DE
19904-4137
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-7155
  • Fax:
Mailing address:
  • Phone: 302-674-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0011649
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number906963
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: