Provider Demographics
NPI:1174931687
Name:BOHAN-HALLENBECK, MELISSA (APRN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BOHAN-HALLENBECK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-2003
Mailing Address - Country:US
Mailing Address - Phone:860-420-8150
Mailing Address - Fax:
Practice Address - Street 1:112 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2045
Practice Address - Country:US
Practice Address - Phone:860-456-6965
Practice Address - Fax:860-456-6969
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311497363L00000X
CT5798363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner