Provider Demographics
NPI:1174694798
Name:MACIEJAK, NICOLE LANGAN (APRN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LANGAN
Last Name:MACIEJAK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:PATRICE
Other - Last Name:LANGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
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:
Mailing Address - Fax:
Practice Address - Street 1:35 DAVIS STREET
Practice Address - Street 2:SBHC
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06515-1601
Practice Address - Country:US
Practice Address - Phone:475-220-7815
Practice Address - Fax:475-220-7842
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3454363LP0200X
CT003454363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004271821Medicaid