Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | 000607 | CT |
NPI | 1124121355 |
---|---|
Provider Name | Christine Fontana |
First Address | New London, CT 06320-4700 |
Second Address | New London, CT 06320-4700 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/09/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4014679 | (05) | CT |
4024972 | (05) | CT |
P15254 | (02) |