1003013525 NPI number — NICOLE MARILYN WAGSCHAL MSN APRN

Table of content: NICOLE MARILYN WAGSCHAL MSN APRN (NPI 1003013525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003013525 NPI number — NICOLE MARILYN WAGSCHAL MSN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAGSCHAL
Provider First Name:
NICOLE
Provider Middle Name:
MARILYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TUBBS
Provider Other First Name:
NICOLE
Provider Other Middle Name:
MARILYN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSN CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003013525
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 BALAZS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06279-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-389-2727
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3514 MAIN ST
Provider Second Line Business Practice Location Address:
CVS- MINUTE CLINIC
Provider Business Practice Location Address City Name:
COVENTRY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06238-1551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-389-2727
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  005423 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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