Provider Demographics
NPI:1154428282
Name:SIMKO, MARYELLEN (APRN)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:SIMKO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 HOCKANUM BLVD
Mailing Address - Street 2:UNIT 5013
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4099
Mailing Address - Country:US
Mailing Address - Phone:860-538-5049
Mailing Address - Fax:
Practice Address - Street 1:95 HOCKANUM BLVD
Practice Address - Street 2:UNIT 5013
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4099
Practice Address - Country:US
Practice Address - Phone:860-538-5049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002739363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004265006Medicaid
CT500001853Medicare PIN