Basic Information
| Provider Information | |||||||||
| NPI: | 1194242008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ECKENRODE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HUNT | ||||||||
| OtherFirstName: | HEATHER | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 67 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037327325 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 130 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037321330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2295575 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 9306 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.