Basic Information
| Provider Information | |||||||||
| NPI: | 1396232476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORN | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606461222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605334679 | ||||||||
| FaxNumber: | 8696454151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2018 | ||||||||
| LastUpdateDate: | 06/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1396232476 | 05 | CT | MEDICAID |