Provider Demographics
NPI:1720194939
Name:GODDARD, ANNA HAZEL (APRN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:HAZEL
Last Name:GODDARD
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:HAZEL
Other - Last Name:TIELSCH-GODDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CPNP-PC
Mailing Address - Street 1:255 HEMPSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6204
Mailing Address - Country:US
Mailing Address - Phone:860-443-2896
Mailing Address - Fax:860-442-5909
Practice Address - Street 1:7 VAUXHALL ST
Practice Address - Street 2:CHILD & FAMILY AGENCY OF SECT, INC.
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5711
Practice Address - Country:US
Practice Address - Phone:860-442-2797
Practice Address - Fax:860-701-3776
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX765853363LP0200X
CT3291363LP0200X
CT73362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse