Basic Information
Provider Information | |||||||||
NPI: | 1982690202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MULLER | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRIDGMAN | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN LPN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 28 CRESCENT ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603586394 | ||||||||
FaxNumber: | 8603586748 | ||||||||
Practice Location | |||||||||
Address1: | 28 CRESCENT ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603586394 | ||||||||
FaxNumber: | 8603586748 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 12/10/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | C089082 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LN0000X | K089082 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LN0000X | 005180 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 363LP0200X | 005180 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 163W00000X | 108351 | CT | N |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 0421040 | 05 | IA |   | MEDICAID | 31674 | 01 | IA | WELLMARK BCBS | OTHER |