Provider Demographics
NPI:1417455213
Name:NELSON, MA MINA SARMIENTO
Entity type:Individual
Prefix:
First Name:MA MINA
Middle Name:SARMIENTO
Last Name:NELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MA MINA
Other - Middle Name:
Other - Last Name:SARMIENTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:37 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-2005
Mailing Address - Country:US
Mailing Address - Phone:860-518-5241
Mailing Address - Fax:
Practice Address - Street 1:158 STATE ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-3202
Practice Address - Country:US
Practice Address - Phone:203-237-1448
Practice Address - Fax:203-237-9187
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11626225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist