Basic Information
| Provider Information | |||||||||
| NPI: | 1194053777 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUNNELL | ||||||||
| FirstName: | MAURICE | ||||||||
| MiddleName: | EDWARDS | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 232 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2009 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 002910 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP2300X | 2910 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 008050090 | 01 | CT | BUNNELL MEDICAID | OTHER | D400292158 | 01 | CT | BUNNELL MEDICARE | OTHER |