Provider Demographics
NPI:1871106179
Name:PUMPHREY, NICOLE D (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:PUMPHREY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 GOSHEN HILL RD EXT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249-2301
Mailing Address - Country:US
Mailing Address - Phone:661-706-6546
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-4123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014789363LF0000X
KS53-79632-032363LF0000X
CT10008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily