=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598555237
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE ROBERGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 08/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 PINE CT
-----------------------------------------------------
City | CROMWELL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06416-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-754-8722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 PINE CT
-----------------------------------------------------
City | CROMWELL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06416-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-754-8722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 134965
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------