Provider Demographics
NPI:1386121895
Name:BOATENG, THERESA
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:BOATENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SHINGLE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-5539
Mailing Address - Country:US
Mailing Address - Phone:203-843-8182
Mailing Address - Fax:203-690-5100
Practice Address - Street 1:150 SHINGLE HILL RD
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516
Practice Address - Country:US
Practice Address - Phone:203-843-8182
Practice Address - Fax:203-690-5100
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-26
Last Update Date:2018-09-25
Deactivation Date:2018-08-24
Deactivation Code:
Reactivation Date:2018-09-25
Provider Licenses
StateLicense IDTaxonomies
CT376J00000X
CTHCA.0001442376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT82-46333610Medicaid
CT82-4633610OtherHOME CARE