Basic Information
Provider Information | |||||||||
NPI: | 1215200654 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PELOW | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | ALYSSA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | THOMAS | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | ALYSSA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 415933 | ||||||||
Address2: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022415933 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605457602 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 282 WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061063322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605459520 | ||||||||
FaxNumber: | 8605459545 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2012 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 337171 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 004957 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 004957 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 004049573 | 05 | CT |   | MEDICAID |