Basic Information
Provider Information | |||||||||
NPI: | 1114906948 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORAN | ||||||||
FirstName: | PATRICE | ||||||||
MiddleName: | MARY | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 231 RAYMOND RD | ||||||||
Address2: |   | ||||||||
City: | WEST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061072539 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603013132 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 30 JORDAN LANE | ||||||||
Address2: | PRIME HEALTHCARE | ||||||||
City: | WETHERSFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 06109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602630263 | ||||||||
FaxNumber: | 8602630567 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/11/2006 | ||||||||
LastUpdateDate: | 06/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 000508 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 004236007 | 05 | CT |   | MEDICAID | 000508 | 01 | CT | APRN | OTHER | 03145972 | 01 | CT | APRN | OTHER |