Basic Information
| Provider Information | |||||||||
| NPI: | 1548477433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | JACQUELINE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 MAIN STREET 2ND FLOOR | ||||||||
| Address2: | ATTN; CREDENTIALING DEPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
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| Practice Location | |||||||||
| Address1: | 134 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064503293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032372229 | ||||||||
| FaxNumber: | 2036861677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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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 | 363L00000X | 002812 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 002812 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 004235900 | 05 | CT | MEDICAID | 004236346 | 05 | CT | MEDICAID |