=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144324229
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE A MAREK APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 06/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 N MAIN ST STE 300
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-313-0448
-----------------------------------------------------
Fax | 860-313-1464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 N MAIN ST STE 300
-----------------------------------------------------
City | WEST HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06107-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-313-0448
-----------------------------------------------------
Fax | 860-313-1464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 03-274181
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 001184
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1184
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------