=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508668252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIA VIVECA SMALLS FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2025
-----------------------------------------------------
Last Update Date | 03/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 ASYLUM AVE STE 3215
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06105-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-714-6980
-----------------------------------------------------
Fax | 860-714-6980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 270 WHITE ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 14618
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------