Basic Information
| Provider Information | |||||||||
| NPI: | 1649641150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLERMONT | ||||||||
| FirstName: | FREDO | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 HALL BLVD FL 3 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060022918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607149333 | ||||||||
| FaxNumber: | 8607148612 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 WOODLAND ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607142750 | ||||||||
| FaxNumber: | 8607148612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2015 | ||||||||
| LastUpdateDate: | 09/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 006309 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 6309 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 006309 | 01 | CT | LICENSE | OTHER |