Basic Information
| Provider Information | |||||||||
| NPI: | 1063487106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YOUNG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 WOODLAND STREET | ||||||||
| Address2: | NEONATAL INTENSIVE CARE | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607144404 | ||||||||
| FaxNumber: | 8607148218 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 ASYLUM AVE STE 2109A | ||||||||
| Address2: | NEONATAL INTENSIVE CARE | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061051719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607146581 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 000953 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LN0000X | 000953 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 004254265 | 05 | CT | MEDICAID |