Basic Information
| Provider Information | |||||||||
| NPI: | 1578794053 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | MARY ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507597 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2009 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0813X | RN2306960 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Geropsychiatric |
No ID Information.