Provider Demographics
NPI:1083663058
Name:ECKENRODE, DELORETTA THERESA (NP)
Entity type:Individual
Prefix:
First Name:DELORETTA
Middle Name:THERESA
Last Name:ECKENRODE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DELORETTA
Other - Middle Name:THERESA
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:31 CHERRY ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3465
Mailing Address - Country:US
Mailing Address - Phone:203-874-7001
Mailing Address - Fax:203-874-7002
Practice Address - Street 1:31 CHERRY ST STE 1
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3465
Practice Address - Country:US
Practice Address - Phone:203-874-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332927363L00000X
CT3709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001644Medicaid