1174694798 NPI number — NICOLE LANGAN MACIEJAK APRN

Table of content: NICOLE LANGAN MACIEJAK APRN (NPI 1174694798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174694798 NPI number — NICOLE LANGAN MACIEJAK APRN

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LANGAN
Provider Other First Name:
NICOLE
Provider Other Middle Name:
PATRICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174694798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
255 HEMPSTEAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW LONDON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06320-6204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 DAVIS STREET
Provider Second Line Business Practice Location Address:
SBHC
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06515-1601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
475-220-7815
Provider Business Practice Location Address Fax Number:
475-220-7842
Provider Enumeration Date:
11/13/2006

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: 363LP0200X , with the licence number:  3454 , 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)

  • Identifier: 004271821 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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