Provider Demographics
NPI:1689981904
Name:ENRIQUEZ, JULIO A (ARNP)
Entity type:Individual
Prefix:
First Name:JULIO
Middle Name:A
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-8095
Mailing Address - Country:US
Mailing Address - Phone:860-788-6404
Mailing Address - Fax:
Practice Address - Street 1:5400 BIG TYLER RD # D
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25313-1178
Practice Address - Country:US
Practice Address - Phone:860-788-6404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC003804363LP0808X
WV105902363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health