=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932605318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEADACHE CARE CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2018
-----------------------------------------------------
Last Update Date | 04/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1741 ELLINGTON RD STE 1
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-2720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-263-3603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 PIERCE RD
-----------------------------------------------------
City | SOUTH WINDSOR
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06074-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | MRS. GRETCHEN T. MICHAELSON
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 860-263-3603
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 003107
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------