Basic Information
| Provider Information | |||||||||
| NPI: | 1184876708 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENIDO-TRUJILLO | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS,APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014361381 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 270 MOHEGAN AVE. | ||||||||
| Address2: | STUDENT HEALTH SERVICES | ||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604392275 | ||||||||
| FaxNumber: | 8608869262 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2008 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 077678 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 003887 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 3887 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 008003100 | 05 | CT | MEDICAID | 803887 | 01 | CT | CONNECTICARE | OTHER |