Basic Information
Provider Information | |||||||||
NPI: | 1083663058 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ECKENRODE | ||||||||
FirstName: | DELORETTA | ||||||||
MiddleName: | THERESA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAWRENCE | ||||||||
OtherFirstName: | DELORETTA | ||||||||
OtherMiddleName: | THERESA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 11350 MCCORMICK RD | ||||||||
Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
City: | HUNT VALLEY | ||||||||
State: | MD | ||||||||
PostalCode: | 21031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4103291071 | ||||||||
FaxNumber: | 4103291054 | ||||||||
Practice Location | |||||||||
Address1: | 67 SAND PIT RD STE 308 | ||||||||
Address2: |   | ||||||||
City: | DANBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 06810 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037437264 | ||||||||
FaxNumber: | 2037923920 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2006 | ||||||||
LastUpdateDate: | 06/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F332927 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 3709 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 008001644 | 05 | CT |   | MEDICAID |