MEDICARE: DARRELL NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	008108	OTHER	CT	LICESEN#

General Provider Information

NPI Number	:	1265626204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRELL NURSE

Provider Business Mailing Address
First Line	:	327 S ELM ST
Second Line	:
City	:	WALLINGFORD
State	:	CT
Zip	:	06492-4818
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 DURHAM RD
Second Line	:
City	:	MADISON
State	:	CT
Zip	:	06443-2676
Country	:	US
Telephone Number	:	203-245-0001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	09/04/2007

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Directions to “ DARRELL NURSE ” Practice Location

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