Provider Demographics
NPI:1528834983
Name:BAMBACK, ERIN KATHLEEN (FNP)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:KATHLEEN
Last Name:BAMBACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 MAMANASCO RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06877-2425
Mailing Address - Country:US
Mailing Address - Phone:203-837-0677
Mailing Address - Fax:
Practice Address - Street 1:30 LAFAYETTE SQ STE 109
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4554
Practice Address - Country:US
Practice Address - Phone:860-454-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT135987163W00000X
NY722804163W00000X
NY352692363LF0000X
CT12298363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse